Twelve-Step Meeting Attendance Form Alcoholics Anonymous (AA

							                        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.