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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!

Full Name (required):

Address (required)
          Street:
          City:
          State:
          Zip Code:

Cell Phone (required):

Home Phone (optional):

Email Address (required):

Sobriety Date (required):

Continuing Care

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

What were those recommendations? (optional) (Check all that apply)
AftercareIOPOPParentingMother's IssuesPsychiatric Follow UpSober HomeAdditional ResidentialAA/NA MeetingsOther

Home & Family

Do you live in Palm Beach County? (optional) YesNo
          If NO, what county and state?

Do you currently RentOwn?

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

How satisfied are you in this area of your life? (optional)
VerySomewhatNot

Education

Have you returned to school or received any specialized training since you left Wayside House? (optional) YesNo
          If YES, please explain:

Employment

Do you work? (optional) Full-TimePart-TimeStay-at-Home-Mom

Please list your current occupation: (optional)

How much has your income increased as a direct result of sobriety>(optional)
          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? (optional) VerySomewhatNot

Sobriety Maintenance

Do you attend AA/NA and/or other self-help programs? (optional) OftenSometimesRarelyNever
          If so, please describe:

Do you have a sponsor? (optional) YesNot at this time

Do you sponsor others? (optional)

Spiritual

In general, how spiritually "connected" would you say you are? (optional) VerySomewhatNot at all

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