Client Interest Form
Miracles Club
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What services are you interested in?
Peer Recovery Mentor
Housing-Transitional
Housing -Permenant
Substance Use Treatment- The Resilience Initiative (TRI)
Help with OHP- for TRI or other medical need
Wellness (exercise and disease prevention) Program
Rent Well or Life Skills Classes
Sober Support
Submit
Should be Empty: