Twelve-Step Meeting Attendance Form
Alcoholics Anonymous (AA)
Student’s Name: __________________________________________
Date of Meeting: ____________________________ Time: ________________
Name of Meeting: _________________________________________
Location of Meeting: _______________________________________
Type of Meeting (Speaker; Big Book; Step; etc.) _________________________
Signature of Meeting Chair: _________________________________________
What was most striking about this meeting and why? _____________________
How likely are you to refer patients to Alcoholic’s Anonymous?
Circle one. Very unlikely; somewhat unlikely; somewhat likely; very likely
Select an Open Meeting to attend. You may use the AA Meeting Schedule to select an
appropriate meeting, or you may call central office phone numbers for respective
meetings, i.e., AA, CA, or NA. Be mindful of group culture, i.e., males should NOT
attend women’s meetings, etc.
You may attend with friends or classmates, but do not attend together in groups larger
than four. You do not want to change the character/culture of the group by bringing a
majority of medical students to the meeting. You are to attend as an observer only.
The meeting chairperson must sign your form. You will find others waiting for the
chairperson’s signature, as forms are required in many instances by parole officers,
probation officers, employers, and other court designees. Protocol will require that you
wait until the meeting has concluded before obtaining the chairperson’s signature.
Complete and return form (no later than September 15) to Karen Drexler, M.D.,
Atlanta VAMC, 1370 Clairmont Road (116-A), Decatur, Georgia 30033.