Correctional Facility Coaching Sign-Up Form

What is the Correctional Facility Recovery Coaching Program?
The Correctional Facility Recovery Coaching Program is a peer-based recovery support program that helps individuals with their recovery. The program is free and available to adult individuals in Minnesota correctional facilities. Through this program, you can work with a  trained peer recovery coach. Recovery coaches have personal experience of recovery from mental health and substance use disorder.
Through this program with a recovery coach, you can:
  • receive personalized recovery coaching, peer support, and community resource navigation from a trained MRC recovery coach
  • strengthen your recovery by exploring what works for you
  • prepare for your release plan and establish your short- and long-term goals
  • develop your support network
Recovery coaches do NOT:
  • make decisions for you
  • diagnose
  • provide counseling or refer to your support activities as "counseling" or "therapy"
  • promote a particular religion/church
  • provide financial or legal support
Q: What happens when I submit my sign-up form?
A: A Recovery Coach will contact you within 2 weeks and discuss how he/she can support your recovery.

Q: How long can I work with a recovery coach through this program?
A: There are no commitment requirements. It goes for as long or as short as you would like to work with your recovery coach. You can continue your work with your recovery coach even after you leave the correctional facility. 
About Us
Minnesota Recovery Connection is a recovery community organization, led by representatives of local communities of recovery. We connect you with .......
  1. Recovery navigation
  2. Peer support
  3. Volunteer opportunities                                                                  
  4. Training and education
  5. Release Planning
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Contact Details

Date of Birth

Release Date (If applicable)

Consent Form
The purpose of the disclosure authorized in this consent is to: provide correctional facility recovery coach support.

I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 &164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time. This consent expires automatically as follows:

I understand and agree to the following:

  1. I grant permission for a volunteer from Minnesota Recovery Connection (MRC) to call me at the above phone number and address to support me in my recovery.

  2. Each time the MRC volunteer calls, he/she will be asking me how my recovery is progressing and if I am in need of additional support (i.e., meetings in area, recovery community centers, safe/sober housing, social events, other resources)

  3. At the time of the call, if I am in need of a referral to a treatment program or detox unit, I will be assisted in finding a program, if I so desire.

  4. If at any time I decide not to take part in this program, I will contact MRC.

By clicking the box and typing in your Full Name and Date, you give Minnesota Recovery Connection permission to contact you at the information provided