The undersigned, without compensation, hereby authorizes the Chicopee Against Addiction, to publish personal information and/or photos/videos either donated or produced by the Chicopee Against Addiction in official publications, media outlets and advertisements for the public and scientific community, so long as such use is in keeping with established standards of good taste. Provided information may be used in whole or edited into a short, concise version.
Your Story and Any Photos or videos can be submitted by email to
Chicopee Against Addiction may use my information, story ( submitted in text or video)
and photo (check one):
• My full name and story/photo/video*:___________
• My first name only and story/photo/video*: ___________
• I prefer that my name not be used and that a pseudonym
be used instead with story/photo/video*: ___________
*videos submitted must be 508 compliant or have a text equivalent word document included for posting.
*Story must be 500 words or less
To educate Americans that substance use treatment and mental health services canenable those with a mental and/or substance use disorder to live a healthy and rewarding life. These Stories of recovery reinforces the positive message that behavioral health is essential to overall health, prevention works, treatment is effective, and people can and do recover.
*Note: Be advised that this information will be in the public domain and may be
reproduced in its entirety or excerpt pieces in official future publications without further permission .
When You can sign with your name, or you can put initials or the word anonymous or use sincerely lost and broken” or whatever is chosen?
By signing below authorizes Chicopee Against Addiction to use all submitted matterials.