Kiosk New Way Form

Sign-In

Please sign-in as member, guest, or first time visitor.

Site*

Request Contact

Please provide the following information and we will get back to you shortly.

This field is hidden when viewing the form

Section Break

Are you:*

Checking-In
Volunteering (members only)
First Time Visit

Have you registered as a Member of our Center?*

Yes
No

Would you like to check in as a guest?*

Yes
No

Selecting NO will enable you to become a member of our center!

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.

Name

First Last

Phone

This field is hidden when viewing the form

I am anonymously attending*

Recovery Group
Recovery Special Event
Center Resource

Non-Participants can not check in for one-on-one sessions.

This field is hidden when viewing the form

I am attending-*

Recovery Group
Recovery Special Event
Center Resource

Please fill our New Member form below if you are not a member! OR change to check-in anonymously.

I am attending:*

Recovery Group

Recovery Group*

Training/Workshop*

Training 1
Training 2

Recovery Event/Activity*

Event 1
Event 2

Please briefly describe what you would like to discuss*

What Volunteer activity are you performing?*

How many hours are you volunteering today?*

Please enter a number from 0 to 24.

This field is hidden when viewing the form

Request Contact

Please provide the following information and we will get back to you shortly.

I am:*

A current Member
Interested in becoming a Member

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: FL01311990 Where First Last's birth date is 01/31/1990.

Name*

First Last

This field is hidden when viewing the form

Please contact me via:*

Phone
Email
Phone or Email

Phone # for Contact*

Email for Contact*

Please briefly describe what you would like to us to contact you about*

New Peer Form

Please create your new participant record.

Name*

First Last

Email*

If you don't have an email address, please input "no@email.com".

Phone*

Please enter (000)-000-0000 if you do not have a phone number

Address*

Street Address Address Line 2 City State ZIP Code

If you do not have an address, please enter 000 Main Street.

How did you hear about us?*

As it pertains to recovery, how would you describe yourself?

I am a person in recovery
I want to be in recovery
I use substances socially
Co-occurring Recovery
I have a family member or a friend who is currently struggling with substance use disorder
I am a Friend/Family Member/Ally
Recovery Coach/Navigator

Demographic Information

Date of Birth*

Race*

White
Hispanic, Latino, or Spanish Origin
Black or African American
Middle Eastern or North African
American Indian or Alaska Native –
Asian –Native Hawaiian or Other Pacific Islander
More than one race
Other

Other Race

Ethnicity

Hispanic
Not Hispanic
Other

Other Ethnicity

Gender (select all that apply)*

Male
Female
Transgender
Prefer to Self-Describe

This field is hidden when viewing the form

Gender*

Male
Female
Nonbinary
Prefer to Self-Describe

Gender

This field is hidden when viewing the form

Do you identify as Transgender*

No
Yes
Prefer not to answer

In what language do you prefer to read or discuss health related materials?

English
Spanish

Are you a veteran?

Yes
No

This field is hidden when viewing the form

Highest Level of Education

Less than HS
HS grad/GED
Some college
Technical School/2-yr degree
4-yr degree (BS/BA)
Graduate degree (Masters or doctorate)
Don't Know
Refused
Not Applicable

What is your employment status?

Working full or part time
Unemployed and looking for work
Not employed and not looking for work
On disability
Student
Retired
Don't Know
Prefer not to answer
Other

This field is hidden when viewing the form

Do you have health insurance?

Yes
No

This field is hidden when viewing the form

COVID-19 Vaccine Status

Fully Vaccinated
Partially Vaccinated
Unvaccinated

This field is hidden when viewing the form

COVID-19 Vaccine Willingness

Currently Vaccinated
Wait and See
Only When Required
Definitely Not

Contact Preferences

This field is hidden when viewing the form

I am interested in:*

Recovery Coaching
Telephonic Recovery Supports
Both Telephonic and In-person Recovery Services
Volunteering

Do you want to be place on our email subscription list?

Yes
No

Are you interested in becoming a Peer Volunteer?

Yes
No

. .

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.

Consent

I agree to the above

Best Days to Call:

Select All
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

Best Time to Call

Morning
Afternoon
Evening
Anytime