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Your Anniversary is a Big Deal!

We want to share in your special day – the anniversary of your sobriety. We honor grads on their anniversary date each month and want to include every single one of you.

Please fill out the form below or download it and mail it to Wayside House so we can celebrate your sobriety date with you!

Name (required)

Current Address (required)
Street

City

State

Zip Code

Home Phone (required)

Cell Phone (required)

Email Address (required)

Sobriety Date (required)

Continuing Care

Did you follow the recommendations made when you were discharged from Wayside House?

 Yes No Some Not Applicable

What were those recommendations? (Check all that apply)
 Aftercare IOP OP Parenting Mother's Issues Psychiatric Follow Up Sober Home Additional Residential AA/NA Meetings Other

Home & Family

Do you live in Palm Beach County?
 Yes No

If NO, what county and state?

Do you currently
 Rent Own

Significant events in sobriety (ex: marriage, divorce, births, deaths, home purchase, etc.)

How satisfied are you in this area of your life?
 Very Somewhat Not

Education

Have you returned to school or received any specialized training since you left Wayside House?
 Yes No
If YES, please explain:

Employment

Do you work?
 Full-Time Part-Time Stay-at-Home-Mom

Please list your current occupation:

How much has your income increased as a direct result of sobriety>
 0-4% 5-15% 16-29% 30-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100%

How satisfied are you in this area of your life?
 Very Somewhat Not

Sobriety Maintenance

Do you attend AA/NA and/or other self-help programs?
 Often Sometimes Rarely Never
If so, please describe:

Do you have a sponsor?
 Yes Not at this time

Do you sponsor others?
 Yes Not at this time

Spiritual

In general, how spiritually "connected" would you say you are?
 Very Somewhat Not at all

Has this area of your life changed as a result of recovery?
Please explain: