Maine – Registered Peer Recovery Coach Application Registered Coach Application Date Of Application Date of Birth * Gender * Applicant Information First Name * Last Name * Address * Address House Number & Street House Number & Street Address Line 2 Address Line 2 City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal County * Phone * Email Address * If we need to contact you regarding your application, please indicate your preference: * Email Phone Education/Training Recovery Coach Academy * Location/Date Recovery Coach Academy * Trainer Ethical Considerations for Recovery Coaches * Location/Date Ethical Considerations for Recovery Coaches * Trainer YOU MUST INCLUDE COPIES OF YOUR CERTIFICATES FOR RECOVERY COACH ACADEMY AND ETHICAL CONSIDERATIONS FOR RECOVERY COACHES * Drop a file here or click to upload Choose File Maximum upload size: 2MB Attestation Statement Recovery is a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential. I attest that I am an individual or affected other in recovery (see page 3 of the MRCCB Applicant Manual) and work each day to support my life in recovery within the following four dimensions: Health * I practice a pathway of recovery for making informed, healthy choices that support my physical and emotional well-being. (For example, abstaining from addictive substances, relationships, or other addictive processes and/or behaviors.) Home * I have a stable and safe place to live. Purpose * I conduct meaningful daily activities and have the independence, income, and resources to participate in society. Community * I have relationships and social networks that provide support, friendship, love, and hope. Signature * Clear Date If you are human, leave this field blank. Continue - Code of Ethics
