New ProfileName* First Last Phone AccessI have a phoneI do not have a phonePhone*Email AccessI have an email addressI do not have an email addressEmail* Date of Birth* Date Format: MM slash DD slash YYYY Permanent AddressI have an permanent addressI do not have an permanent addressAddress* 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 Gender*FemaleMaleTransgenderOtherNonbinaryPrefer not to answerRace*American Indian or Alaska NativeAsianHispanic, Latin, or Spanish OriginBlack or African AmericanMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderMore than one raceWhiteOtherAre you interested in becoming a volunteer?*YesNoHow did you hear about us?*Treatment ProviderHealthCare ProviderCriminal Justice System (Probation, etc.)Someone else who comes to FOCUSCommunity Agency (ex, City Mission, Hope House, NAMI, etc)Friend or FamilyI've been coming here for a long time
