ARC Fitness Recovery Programme Interest ARC Fitness Addiction Recovery Programme Question Title * 1. Personal Details Name Address Address 2 City/Town ZIP/Postal Code Email Address Phone Number Question Title * 2. Are you Interested in taking part in a 6 week recovery programme? Yes No Question Title * 3. Problem Area Alcohol Drugs Both Question Title * 4. Length of Time in Recovery Question Title * 5. Are you currently engaged with Addiction Services in the community? Yes No Other (please specify) Question Title * 6. Are you currently engaged / involved with Probation Services / PSNI / Youth Justice Yes No Other (please specify) Question Title * 7. Current level of fitness Exercise 1-2 days per week Exercise 3-4 days per week Exercise 5-6+ days per week No exercise at all Question Title * 8. Any physical health condition that would prevent you from exercise? Question Title * 9. Would you like me to send further Programme information? Yes No Done