Donate - Mid-Coast Recovery Coalition

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Your Donation Keeps Our Work Alive

We are passionate about supporting recovery towards health and wellness in our communities – and we need your help to make that work happen.

Donate Today!
Please help us to sustain and expand our services with a secure online donation through PayPal!

OR mail your gift to:

Mid-Coast Recovery Coalition
PO Box 1002
Camden, ME 04843

All gifts to the Mid-Coast Recovery Coalition are tax deductible.

Wish List

If you would like to make a donation of physical goods, below is a list of needed items:

*Paper Products – TP, Paper Towels, Napkins, Tissues

*Cleaning Supplies

*Dish Soap

*Hand Sanitizer

*Long underwear for men, women and children

*Winter Hats and Gloves

Please contact (207) 701-1182 or email info@midcoastrecovery.org for more information

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Full Name(Required)

First Last

Date(Required)

Date Of Birth(Required)

dd/mm/yyyy

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Email(Required)

Emergency Contact(Required)

Name, Phone Number, & Relation

Current Treatment Center

Treatment Center Phone Number

Primary Counselor

Length of Program

Discharge Date

Past Treatment Programs

City/State

Counselor Name

Entry/Exit Date

Have you ever lived in a sober house?(Required)

Yes

If yes, when and where?

Substance Use(Required)

Drug

Length of Abuse

Time Since Last Use

Which recovery program are you currently working, or interested in? (i.e. A.A., N.A., Smart Recovery, etc.)(Required)

What meetings do you attend?(Required)

Do you have a sponsor?(Required)

What is your source of income?(Required)

Monthly Income(Required)

Pending Legal Matters (please explain)

Any felony convictions? If “yes”, please explain(Required)

Are you required to register as a sex offender?(Required)

Have you been convicted of arson?(Required)

Do you have any other mental health diagnosis?(Required)

What is that diagnosis (and treatment)?

Have you ever experienced any suicidal ideations, attempts, or received in-patient treatment for self-harming behaviors? If yes, when?(Required)

Current Medications and Dosage(Required)

Why do you think you are a good fit for sober living?(Required)

Signature

Date

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