Moar Recovery Day

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Sign-In/Drop-In/First Time Visit
If you are attending a recovery group, event, center resource, or training, select Check-In. If you are want additional information, please select Drop-In.
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Area*
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Request Contact
Please provide the following information and we will get back to you shortly.
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Section Break
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Are you:*
- Checking-In
- First Time Visit
Have you registered as a Member of MOAR?*
- Yes
- No
Would you like to check in as a guest?*
- Yes
- No
Would you like to become a member of MOAR? Please click here to fill out the new member form.
First Name*
Initial of Last Name*
Guest Email*

If you don't have an email address, please input "no@email.com".
Your Participant Short Code:*
Your participant short code is your first initial, last initial, birth month, day and year in the following format: FL10211901 Where First Last's birth date is 10/21/1901.
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I am attending:*
- Recovery Day
- Recovery Community Education Group
- Training
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Recovery Community Education Group*
- Action for Recovery
- AREAS Meeting
- PAREnt Project
- Women's Space
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Training Type*
- Recovery Messaging
- Advocacy 101
- CORI
- Introduction to MOAR
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Event Type*
- Event 1
- Event 2
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Center Resource*
- Resource 1
- Resource 2
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Please briefly describe what you would like to discuss*
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Request Contact
Please provide the following information and we will get back to you shortly.
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I am:*
- A current Member
- Interested in becoming a Member
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Please Enter Your Participant Short Code:*
Your participant short code is your first initial, last initial, birth month, day and year in the following format: FL10211901 Where First Last's birth date is 10/21/1901.
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Name*
First Last
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Please contact me via:*
- Phone
- Email
- Phone or Email
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Phone # for Contact*
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Email for Contact*
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Please briefly describe what you would like to us to contact you about*
New Member - Recovery Day
Please create your new member record.
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Select an Area to become a New Member*
Name*
First Last
Phone*
Please enter (000)-000-0000 if you do not have a phone number
Email*

If you don't have an email address, please input "no@email.com".
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Address*
Street Address Address Line 2 City State ZIP Code
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How did you hear about us?
- Friend/Family
- Treatment Provider
- Probation officer
- Emergency Department
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Reason for Submission*
- Select All
- Housing
- Employment
- Education
- Connection to treatment
- Connection to recovery community
- Recovery support
- Probation
- Overdose
- Co-occurring
- Multiple treatment episodes
- Other
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Reason for Referral, if Other:
Demographic Information
Date of Birth*
MM slash DD slash YYYY

If you are uncomfortable providing your birthdate, we encourage you to use your Recovery date.
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Was the date used your birthdate?*
- Yes
- No
Race*
- Black or African American
- Asian
- Native Hawaiian/Pacific Islander
- Alaska Native
- White
- Native American
- Other
- Refused
Race, if Other:*
Ethnicity
- Hispanic or Latino
- Not Hispanic or Latino
- Refused
Gender*
- Male
- Female
- Transgender
- Non-binary
- Prefer to Self-Describe
- Refused
Gender, if Other:*
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Do you have health insurance?*
- No
- Yes
- Unknown
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Where do you live?*
- Housed
- Unhoused
- Shelter
- Recovery Residence
- Residential Treatment
- Institution
- Halfway House
- Other
- Refused
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Describe your living situation, if Other:
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Please select which recovery path(s) you use.*
- Abstinence
- 12-Step Recovery
- Support groups
- Natural Recovery
- Peer Recovery support
- Medication-assisted Recovery
- Harm Reduction
- Alternative/Holistic Recovery
- Other
- Unknown
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Recovery Path, if Other:*
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COVID-19 Vaccine Status
- Fully Vaccinated
- Partially Vaccinated
- Unvaccinated
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Would you like your receive the MOAR newsletter?*
- Yes
- No
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Would you be interesting in volunteering for MOAR in your area?*
- Yes
- No
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Contact Preferences
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I am interested in:*
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
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Best Days to Call:
- Select All
- Mondays
- Tuesdays
- Wednesdays
- Thursdays
- Fridays
- Saturdays
- Sundays
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Best Times to Call:
- Morning (Before 9)
- Late Morning (9 to 12)
- Afternoon (12 to 3)
- Late Afternoon (3 to 6)
- Evening (6 to 9)
- Late Night (After 9)
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Consent Form
The purpose of the disclosure authorized in this consent is to receive recovery support. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 &164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time. I understand and agree to the following: 1. I grant permission for a volunteer to call me at the above phone number, email, and/or address to support me in my recovery. 2. Each time the volunteer calls, he/she will be asking me how my recovery is progressing and if I am in need of additional support (i.e., meetings in area, recovery community centers, safe/sober housing, social events, other resources). 3. At the time of the call, if I am in need of a referral to a treatment program or detox unit, I will be assisted in finding a program, if I so desire. 4. If at any time I decide not to take part in this program, I will contact the center or tell the volunteer when he/she calls.
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Consent
I agree to the above
BECOME A MEMBER OF MOAR
Name*
First Last
Gender:
- Male
- Female
- Transgender
- Non-binary
- Prefer to Self-Describe
- Refused
Gender-
Race:
- Black or African American
- Asian
- Native Hawaiian/Pacific Islander
- Alaska Native
- White
- Native American
- Other
- Refused
Race-
Date of Birth
MM slash DD slash YYYY

If you are uncomfortable providing your birthdate, we encourage you to use your Recovery date or a special date.
Was the date used your birthdate?
- Yes
- No
Address:
Street Address Address Line 2
Address-*
City State ZIP Code
Email:*

If you don't have an email address, please input "no@email.com".
Phone
Are you an individual with lived experience, a family member and/or a friend?
- Individual with lived experience
- Family
- Friend

Sign-In/Drop-In/First Time Visit

Request Contact

Section Break

Request Contact

New Member - Recovery Day

Demographic Information

Contact Preferences

Consent Form

BECOME A MEMBER OF MOAR