Kiosk AICDAC Form

Check-In and Check-Out

Site*

Request Contact

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

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Are you:*

Checking-In
Checking-Out

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.

Do you want to register as a Member of our Center?*

Yes
No

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".

What brings you into the Center today?*

CRS Appointment
Support Group
Activity
Visitor/Guest of a Member

Please see a staff member to complete your registration.

Name*

First Last

What Center Resources did you utilize today?*

Computer/Laptop
Library
Socialization
Game
Activity
Gym Equipment
TV
Support Group
CRS Appointment

Game*

Board/Card/ Puzzle
Skee Ball
Darts
Bubble Hockey
Pool
Basketball
Foosball
Xbox
PlayStation

Activity*

Game Activity
Arts/Crafts
Personal Development Activity
Education/Information
Special Event/Party
Recovery Pathway Activity

Gym Equipment*

Weight Machine
Bike
Treadmill
Elliptical

Support Group*

All Recovery Meeting
Family Support Group

Which CRS did you have an appointment with?*

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.

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".

Address*

Street Address Address Line 2 City State ZIP Code

County of Residence

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How did you hear about us?

Friend/Family
Treatment Provider
Probation officer
Emergency Department

Reason for Referral*

Reason for Referral, if Other:*

Demographic Information

Date of Birth*

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
Other
Refused

Gender, if Other:*

Do you have health insurance?*

No
Yes
Unknown

What is your Health Insurance?*

Private- Employer
Private- Individual
Medicare
Medicaid
Medicaid and Medicare
Other

Employment Status*

Employed, Full Time
Employed, Part Time
Unemployed, Looking for work
Unemployed, Not looking for work
Disabled
Volunteer
Retired
Other
Refused

Check all that apply to you:*

IV
Overdose Survivor
Pregnant
Veteran
Co-Occurring(substance use disorder AND mental or physical health disorder)
Medical Marijuana
Pharmacotherapy(Buprenorphine, Naltrexone, Methadone)
Probation/Parole(current)
None

Drug(s) formerly used:

Where do you live?*

Describe your living situation, if Other:*

Please select which recovery path(s) you use.*

Recovery Path, if Other:*

Are you currently receiving treatment for Substance Use Disorder?*

Yes
No

Where do you receive treatment for Substance Use Disorder?*

Are you currently receiving treatment for Mental Health Disorder?*

Yes
No

Where do you receive treatment for Mental Health Disorder?*

What is your Recovery Date?*

Do you currently have a Case Manager through Armstrong Indiana Clarion Drug and Alcohol Commission?*

Yes
No

Who is your Case Manager?*

Do you currently have a CRS through Armstrong Indiana Clarion Drug and Alcohol Commission?*

Yes
No

Who is your CRS?*

Are you interested in learning more about CM and/or CRS services through Armstrong Indiana Clarion Drug and Alcohol Commission?*

Yes
No

If you have immediate needs, please call 724-545-1614.

What does the term "Recovery" mean to you?*

Describe you current state of Recovery:*

Why do you want to become a Member of Recovery Capital?*

How can Recovery Capital help your Recovery?*

Recovery Guidance
Recovery Education
Health/Wellness
Life Skills
Socialization
Recovery Support Groups
Supportive Environment
Activities
None

Are you interested in Telephone Recovery Support?*

Yes
No

If you answer yes, you will be called 1 time per week based on the availability selected. You can change your calling preferences at a later date.

Best Days to Call*

Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays

Best Times to Call*

Late Morning (9 to 12)
Afternoon (12 to 3)
Late Afternoon (3 to 5)

Step 1 of 2

Check-In and Check-Out

Request Contact

Section Break

Request Contact

New Member

Demographic Information

Recovery Capital Member Agreements

Contact Preferences