Divas Update Form

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Check-In/Leave a Message
If you are attending a recovery group, event, center resource, or training, select Check-In. If you are an existing member and would like to leave a message for staff, select Leave a Message.
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Site*
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Are you:*
- Checking-In
- Leaving a Message (Existing Member)
Have you registered as a Member of our Center?*
- Yes
- No
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.
Would you like to check in as a guest?*
- Yes
- No
Guest Name*
You may enter your first name, a nickname or Anonymous if you do not want to give your full name.
Guest Phone
Guest Email
Please click here to fill out the new member form.
I am attending:*
- Recovery Group
- Recovery Special Event
- Recovery Coaching (One-On-One)
- Center Resource
- Training
I am attending:*
- Recovery Group
- Recovery Special Event
- Center Resource
- Training
Recovery Group*
- All Recovery
- AA 12 Step
- NA 12 Step
- DTR
Event Type*
- WOAD Alumni
- WOAD Orientation
- She Works Graduation
- Divas Foundation Graduation
- Galentines
- Mothers Day
- Memorial Day
- Thanksgiving Potluck
- Recoveryfest
- SHE Roars
- Get LIT Summer Camp
- Schooldayz Academy
- Listening Session
Center Resource*
- GED
- ART Therapy
- Financial Education Workshops
- Homebuyers Workshop
- Gardening & Agriculture
- Community Service
- Job Search
- Resume Building
- Mock Interviews
- Community Kitchen Meals
- Community Partners Collab
Training Type*
- SHE Works
- Divas Foundations
- Freedom Experience
Please briefly describe what you would like to discuss*
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
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 Member
Please create your new member record.
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
Services Interested in Today*
- Peer Coach (1:1)
- Recovery Support Group
- Workforce Development - Job Search
- Workforce Development - Resume Assistance
- Community Service
- Sex Trafficking Education
- Community Kitchen
- Art Therapy
- MAT Medication Education
- Transportation
New Member?*
- New Member
- Returning Member or Other
Please check the box to indicate if you are a new member.
County*
Other County*
Please list your county if you responded Other to the previous question.
Ethnicity*
- Caucasian
- African American
- Latino
- Asian American
- Native American
What is your DOC (drug of choice)?*
- Alcohol
- Marijuana
- Cocaine/Crack
- Methamphetamines
- Inhalants
- Hallucinogens
- Opioids
- GHB
- Fentanyl
- Other
Drug of Choice if Other*
If you selected Other for the previous question, please describe.
Are you a returning citizen?*
- Yes
- No
Are you a mom?*
- Yes
- No
Do you have a history of the following?*
- Sex Worker
- Sex Trafficking Survivor
- Exotic Dancer
- Massage Parlor Work
- Online Sex Worker
- Survival Sex
- Sex for Substances
- Refugee
- None of the Above
Are you a trauma survivor?*
- Sexual Violence
- Domestic Violence
- I am not a trauma survivor
- Other
If you answered Other to the previous question, please describe:*
Describe your housing*
- Housed
- Unhoused
- Shelter
- Recovery Residence
- Residential Treatment
- Institution
- Halfway House
- Other
- Refused
Describe your living situation, if Other:*
Have you been homeless in the past year?*
- Yes
- No
Are you currently employed?*
- Yes
- No
- Job Searching
- SSI
Current Occupation + Place of Employment*
How did you hear about us?
- Friend/Family
- Probation officer
- Emergency Department
- ABHS
- Serenity Grove
- Twin Lakes
- All Recovery Homes
- The Cottage
- Project Safe
Reason for Referral*
- Select All
- Housing
- Employment
- Education
- Connection to treatment
- Connection to recovery community
- Recovery support
- Probation
- Overdose
- Co-occurring
- Multiple treatment episodes
- Family Preservation Program
- Thrive
- Family Treatment Court
- Transportation
- She ROARS
- Sexual Violence
- Sex Trafficking Survivor
- Other
Reason for Referral, if Other:*
Do you identify as a person in recovery?*
- Yes
- No
What is your recovery collateral?*
- NA
- AA
- All Recovery
- HA
- Prayer/Faith
- Art
- MAT
- Family
- Dharma
- Peer Coaching
- Unsure
- Other
Recovery collateral if other*
If you answered Other to the previous question, please describe.
I understand that if I make statements or threaten to harm myself or others, Divas Who Win is a mandatory reporting organization.*
- Yes
- No
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Demographic Information
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Date of Birth*
MM slash DD slash YYYY
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Race, if Other:
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Ethnicity
- Hispanic or Latino
- Not Hispanic or Latino
- Refused
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Gender*
- Male
- Female
- Transgender
- Non-binary
- Other
- Refused
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Gender, if Other:
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Do you have health insurance?*
- No
- Yes
- Unknown
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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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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:
- Select All
- 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)
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.
Consent
I agree to the above

Check-In/Leave a Message

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Request Contact

New Member

Demographic Information

Contact Preferences

Consent Form