Registration Form

Aware Ai Registration

Recovery Assistance Program

With the year long Recovery Assistance Program you will receive weekly video prompts, monthly progress surveys and quarterly mental health assessments. An AwareAi Progress Analyst will meet with you once a month to review your progress to date and highlight key areas the technology picks up on.

Random Drug Testing

The Random Drug Testing option provides you with randomly prompted video drug screenings to the email address listed and saliva drug tests delivered to your door.

Client Name *

First

Last

Start Date *

Date of Birth *//

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client Email *

This will be the email that your AwareAi check-in's are sent to.

Client Phone Number *

Emergency Contact

Emergency Contact Name *

First

Last

Emergency Contact Email *

Emergency Contact Phone

Support Contact

We recommend selecting at least one person from your network as your Support Contact to accompany you in your recovery journey. This could be a parent or guardian, therapist, sponsor, relative or supportive friend. This person will receive monthly reports, updates of your progress, and will be alerted as to any critical items triggered in the video responses.

Relationship to Support Contact *

Additional Support Contact Information

Sharing information from the AwareAi platform with more than one person in your support network will significantly benefit your recovery process. The individual listed will receive monthly reports, updates of your progress, and will be alerted as to any critical items triggered in the video responses.

Relationship to Additional Support Contact *

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