Group/Event AttendanceSite*Serenity House of FlintWould you like to remain anonymous?*YesNoAre you an existing participant?*YesNoPlease enter your participant short code*Your participant short code is your first initial, last initial, birth month, day and year in the following format: FL02011901 Where First Last's birth date is 2/1/1901.How did you hear about us?*TreatmentHealthCareCriminal Justice SystemPeerCommunity AgencyFriend/FamilyFirst Name*Last Name*Phone*If you don't have a current phone number, please input "No phone".Email* If you don't have an email address, please input "no@email.com".Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birth Date* Date Format: MM slash DD slash YYYY Gender*MaleFemaleTransgenderOtherNonbinaryPrefer not to answerRace*WhiteHispanic, Latin, or Spanish OriginBlack or African AmericanMiddle Eastern or North AfricanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianMore than one raceOtherAre you receiving government assistance like medicaid, medicare, SNAP, etc?*YesNoAre you a person in recovery?*YesNoHow long have you been in recovery?* Date Format: MM slash DD slash YYYY What event are you attending?*Awareness eventDrumming CircleHolistic Healing Hour: Acudetox & AromatherapyHolistic Healing Hour: Recovery Reiki (r) and Talking CircleCommunity AcupuncturePAC time Yoga classRecovery Reiki TrainingAdolescent Holistic Healing HourOnline workshopOtherSUD Conference Session*One-on-one EFT sessionOne-on-one Reiki & Meditation sessionOne-on-one Naturopathy ConsultationRecovery Reiki GroupHealing EFT WorkshopOther Meeting Type*As a result of the Covid-19 have you returned back to active use?*YesNoIf your in active use of substances during the Covid-19, has your substance use...*increaseddecreasedstayed the samedoes not applyPre-session QuestionsHow would you rate the physical pain in your body?NoneLowModerateHighWorst PossibleWhat is your level of anxiety?NoneLowModerateHighWorst PossibleWhat is your level of stress?NoneLowModerateHighWorst PossibleWhat is the level of anger you feel?NoneLowModerateHighWorst PossibleHow would you rate your overall wellness?Worst PossibleLowModerateGoodExcellentPost-session QuestionsHow would you rate the physical pain in your body?NoneLowModerateHighWorst PossibleWhat is your level of anxiety?NoneLowModerateHighWorst PossibleWhat is your level of stress?NoneLowModerateHighWorst PossibleWhat is the level of anger you feel?NoneLowModerateHighWorst PossibleHow would you rate your overall wellness?Worst PossibleLowModerateGoodExcellent
