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 ________________________________________________________________________ Instructions: 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.
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