Treatment Facilities Inventory

This inventory form will be used by the Area Treatment Facilities Standing Committee to gain a better understanding of the AA fellowship’s cooperation with treatment facilities in Utah. District standing chairs and committee members will complete the Facility Inventory Forms. The information gathered will only be made available to the Treatment Facilities Standing Committee and will not be shared outside of the fellowship.

Facility Name :
Street Address:
PO Box:
City, State, Zip:
,

  
Telephone:
Fax:
E-mail:
   
Type of Facility: (Check all that apply)
Licensed

Medical / Detox

Outpatient

Residential / Inpatient

Youth

Prevention

Halfway house
Administrator:
Admin Phone:
Counselor:
Counselor Phone:
Area 69 District:
Type of A.A. Cooperation:
Introduction letter

Literature Rack

Panel Presentations

Bridging the Gap Program

Weekly A.A. meeting

Daily A.A. meeting

A.A. Speaker meeting

Other (Please indicate):
Monthly Frequency of A.A. contacts:
Last A.A. Contact:

(YYYY/MM/DD)
   
Your Name:
Service Position:
   
Name of A.A. Group:
Open / Closed?
Current GSR: