Contact Info
First Name
Last Name
Phone
*
Email
*
City
State
Recovery/Background
Which best describes you?
*
Person in recovery
Family member / supporter
Therapist or mental health professional
Recovery / wellness coach
Healthcare professional
Community organizer
Other
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Do you currently have an audience or community?
No
Small community (under 500 people)
Growing community (500-5,000)
Established audience (5,000+)
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Where would you most likely share Recovered Life?
Social Media
Friends or personal network
My recovery meetings or support groups
A private online group or community I’m part of
My email list or newsletter
My podcast, YouTube channel, or content platform
Through my professional work (therapy, coaching, wellness, etc.)
Other
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Intent
Which roles are you interested in?
Promoting Recovered Life
Circle Leader (host peer meetings)
Contributor (share professional expertise)
Community volunteer
None of the above
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Why do you want to become a Recovered Life Ambassador or Leader?
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