Check-In/Drop-In/First Time Visit
If you are attending a recovery group, event, center resource, or training, select Check-In.
If you are here to see your Recovery Coach, select Drop-In.
Request Contact
Please provide the following information and we will get back to you shortly.
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Section Break
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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.
Non-Participants can not check in for one-on-one sessions.
- Please click here fill to out the new member form.
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Request Contact
Please provide the following information and we will get back to you shortly.
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.
New Member
Please create your new member record.
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Please enter (000)-000-0000 if you do not have a phone number
If you don't have an email address, please input "no@email.com".
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Demographic Information
Contact Preferences
Contact Preferences
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.
Intake Information
Insurance Information
If Group ID is not available, input the Medicaid ID Number Here as well
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Socioeconomic Information
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Physical & Behavioral Health Information
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Family Information
If none, please enter 0.
Legal Information
If none, please enter 0.
If none, please enter 0.
