I would like to have an A.A. Temporary Contact who will provide a link for me to the A.A. community through meetings and introduction to other A.A. members. You will be contacted by the HTF Coordinator.
Full Name (required)
Contact Phone/Mobile Phone
Email (required)
Gender (required) —Please choose an option—MaleFemaleOtherPrefer Not To Say
Name of facility, name of counselor, telephone number at the facility where you can be reached (required)
Address of facility
City (required)
Zip Code (required)
Expected discharge date (if available)
Address after discharge
Languages Spoken (Optional) EnglishPolishSpanishMandarin/CantoneseJapaneseFrenchOther
Age Group (optional) Under 2020-something30-something40-something50 plus60 plus70 or more
