This is a pledge between two OA members to support and to be accountable to one another. If you think this agreement could be helpful for you, fill out
your name and other information as the “I” on one side of the form and have another OA member complete the other half. Cut the forms apart and
exchange sides. Place the agreement in a prominent spot to remind you of your commitment to recovery and to service.

RECOVERY INSURANCE POLICY

I,___________________________________on this day do hereby give_____________________________________ (a recovering OA member) permission to take me to a meeting if she/he does not receive a phone call from me within ___ days of our last conversation; or if she/he does not see me at an OA meeting within the last ___ weeks. She/he has the right to use all means of communication to contact me, including contacting ______________________________________ (a friend/ relative) for assistance agreement may only be terminated after we have had contact and mutually agree to end this agreement.

Signed:________________________________ Date: ________

My address: __________________________________________

____________________________________________________

____________________________________________________

My phone numbers: __________________________________

____________________________________________________

My email: ____________________________________________

____________________________________________________

Friend/relative’s phone no.: ____________________________

Always to extend the hand and heart of OA to all who share my compulsion; for this I am responsible.