OCAP Sponsor

CENTRAL TEXAS TREATMENT CENTER
OFF-CAMPUS ACTIVITY SPONSOR AGREEMENT
FOR
_______________________________________________________
Name of Resident
To provide appropriate accountability for the resident while outside the center, a sponsor is necessary to oversee and verify
scheduled off-campus activities. In order for a resident of CTTC to receive approval for activities outside the center, approved
sponsors MUST AGREE to the following:
1.
You are aware of and agree to carry out, without deviation, the resident’s proposed off-campus activity itinerary. The
resident is to have informed you prior to receiving approval for a particular activity. We may call to verify that this has been
done.
2. You will sign the center’s required forms before and after the activity.
3. You agree to verify and account for the resident’s whereabouts while away from the center. This means the resident must
be reasonably observed at all times.
4. You may be contacted at any time during the activity by center staff members.
5. You will contact center authorities at (512) 943-1211 if the resident violates any condition of the off-campus activity
agreement or condition of probation. The use of illegal drugs, alcohol or unauthorized prescription drugs is a serious
violation and must be reported to center staff immediately.
6. You will participate in the sponsor orientation if applicable.
7. You will provide a driver license or other photo identification when you arrive at the center and you will permit it to be
copied by center staff.
8. You acknowledge that the resident’s probation officer can deny approval of a sponsor when necessary.
9. You are at least 18 years of age.
10. You are in 12-step recovery yourself if you are also attempting to gain approval as a 12-Step Sponsor.
11. You will attend at least 6 Al-Anon meetings.
By signing this agreement, you are accepting the responsibilities of the sponsorship as defined above, as well as, affirming that all
the information on the sponsor questionnaire are true, to the best of your knowledge.
____________________________________________________________
Sponsor’s Signature
__________________________
Date signed
____________________________________________________________
Witness’ Signature
__________________________
Date signed
The Sponsor Questionnaire, Off-Campus Activity Sponsor Agreement and a copy of a valid state photo ID must be submitted to the
office prior to your being considered as a sponsor. If you have any questions, call (512) 943-1211.
Send completed forms to the resident at PO Box 488, Granger, TX 76530-0488
--------------------------------------------------------------------for office use only--------------------------------------------------------------------
Approve / Denied by ____________________________________________
Date _____________________
CENTRAL TEXAS TREATMENT CENTER
OFF-CAMPUS ACTIVITY SPONSOR QUESTIONNAIRE
Resident Name _____________________________________________________
Date _______________________________
Sponsor Name _____________________________________________________
Relationship _________________________
Address _____________________________________________________________________________________________________
Street
City
State & Zip
Home Phone ___________________________________________
Mobile Phone _____________________________________
Date of Birth ___________________________________________
Age __________________
Gender _________________
Occupation __________________________________________________________________________________________________
Employer________________________________________________________________________
Phone____________________
Employer’s Address ___________________________________________________________________________________________
Street
City
Driver License # _____________________________________________
Have you ever been convicted of a felony?
NO
State _____________
State & Zip
Expiration Date ______________
YES (explain)
____________________________________________________________________________________________________________
Charge
Date
Have you ever been convicted of a Class B or greater Misdemeanor?
NO
YES (explain)
____________________________________________________________________________________________________________
Charge
Are you currently on probation or parole?
Date
NO
YES
Length of time you have known the resident _____________________________________________________________________
Have you ever used drugs or consumed alcohol while in the company of the resident?
How would you describe your relationship with the resident?
In your opinion, what are the resident’s strengths?
In your opinion, what are the resident’s weaknesses?
NO
YES
What do you think about the resident’s continued association with the “old crowd” or “old friends” ?
What do you think the resident needs to do to remain drug and/or alcohol free?
What do you think the resident needs to do to remain crime free?
What do you think you can do to help the resident remain drug/alcohol and crime free?
What do you think CTTC can do to help the resident most while he/she is at the center?
To your knowledge, are there other family members or associates who have significant influence on the resident?
Please use the space below to list their name and relationship to the resident.
Did you ever reside at Central Texas Treatment Center?
NO
YES (How long ago?) ___________________________________
Are you currently involved in a 12-Step recovery program?
If yes, please answer the following:
NO
YES
How long have you been in recovery?
How many people have you sponsored?
How many people are you currently sponsoring?
Do you currently have a sponsor? YES
NO
In an average month, how many 12-Step meetings do you attend?
What is the name of your home group?
Where is your home group located?
Thank you for your honest answers. This information will help us better support the resident.
CENTRAL TEXAS TREATMENT CENTER
AL-ANON MEETINGS ATTENDED
Individuals applying for OCAP sponsorship are required to attend at least 6 Al-Anon meetings in order to be approved.
Please request the meeting chair to sign or initial and date this form.
To obtain Al-Anon meeting times and locations, contact:
World Service at 888-425-2666 or
Email the Austin area at austinalanon.org or
Visit www.texas-al-anon.org
OCAP Sponsor Name: __________________________________
Resident Name: _____________________________________
Group Name: ______________________ Date: ____________ Time: ____________ Chair Signature: _________________________
Group Name: ______________________ Date: ____________ Time: ____________ Chair Signature: _________________________
Group Name: ______________________ Date: ____________ Time: ____________ Chair Signature: _________________________
Group Name: ______________________ Date: ____________ Time: ____________ Chair Signature: _________________________
Group Name: ______________________ Date: ____________ Time: ____________ Chair Signature: _________________________
Group Name: ______________________ Date: ____________ Time: ____________ Chair Signature: _________________________
Please return this form to the resident’s probation officer, ___________________________________________________________
THIS FORM BECOMES A LEGAL DOCUMENT