My Recovery Expression of Interest - NT Mental Health Coalition

Complete the following questions to express your interest in participating in a scheduled My Recovery program. We will contact you to confirm receipt and your enrolment in the program you have nominated. Please note: If you are completing this form for someone else, it is expected that person has provided you with consent.

Name:*

Address:*

Phone:*

Email*

Why do you want to do the My Recovery program?*

select all that apply

What recovery skills or strengths would you like to develop?*

select all that apply

Communication
How to speak up for myself
Discovering my story
Other

Do you have someone who will support you through this program?*

Yes
No

If yes, why did you choose them?

I acknowledge that I am:*

select all that apply

Over 18
Living with mental health challenges or other related issues (trauma, alcohol and/or other drug issues)
On my own journey of recovery
Prepared to access support during the My Recovery program
Prepared and willing to commit to attending all 9 sessions of the program

Details of My Recovery program you want to attend:*

Please write down the name of the My Recovery program and start date for the program that you want to attend:

Challenges or barriers to participation

If there are potential barriers to your participation that you would like us to talk to you about, please let us know (e.g. transport, kids, work or other commitments). There may be practical ways we can help.

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