Kiosk Bridge Form

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Check In
If you are attending a recovery group, event, center resource, or training, select Check-In.
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Site*
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Are you:*
- Checking In
- Volunteering
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*
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Guest Phone
If you do not have or do not with to leave a phone number, please enter 000-000-0000.
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Guest Email

If you do not have or do not with to leave an email address, please enter no@email.com.
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
Recovery Group*
- Just For Today/Sunday Funday
- Smart Recovery
- Dharma
- Bridge To Hope Family Support
- Yoga
- Spiritual Tune up
- Big Book Babes
- Alcoholics Anonymous Malden Men's
- New Chapter Woman Meeting
- Gamblers Anonymous
- N/A Ultimate Weapon
- Friday Night All Recovery Meeting
- Check up from the Neck Up
- Community Meeting
- Daily Reflections
- Kats Sewing Workshop
- Money Management
Event Type*
- Events at BRC
- Events at Other Centers
- Outreach Events
Center Resource*
- Housing
- Sober Living scholarships
- Detox/Treatment/Sober House
- Recovery Coaching
- Resume Building
- Job Search
- Food Assistants
- Clothing
- Legal/CORI
Training Type*
- Narcan
- CHA Health & Wellness
- Peer Leader
- Financial
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Please briefly describe what you would like to discuss*
What Volunteer activity are you performing?*
- Volunteer for Fridges
- Volunteer Thursdays
- Volunteer In Center
- Volunteer for Events
- Volunteer for Outreach
- Other
Volunteer activity, if Other:*
How many hours are you volunteering today?*
Please enter a number from 0 to 24.
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
Address*
Street Address City State ZIP Code
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Recovery Status*
- Person in recovery
- Person who uses drugs
- Young person
- Family member
- Professional
- None of the above
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How did you hear about us?
- Friend/Family
- Treatment Provider
- Probation officer
- Emergency Department
EMS Number
Reason for Referral*
- Housing
- Employment
- Education
- Connection to treatment
- Connection to recovery community
- Recovery support
- Probation
- Overdose
- Co-occurring
- Multiple treatment episodes
- Other
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
Where do you live?
- Housed
- Unhoused
- Shelter
- Recovery Residence
- Residential Treatment
- Other
- Refused
Describe your living situation, if Other:
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
Recovery Path, if Other:
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COVID-19 Vaccine Status
- Fully Vaccinated
- Partially Vaccinated
- Unvaccinated
Contact Preferences
I am interested in:*
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
Best Days to Call:
- Select All
- Mondays
- Tuesdays
- Wednesdays
- Thursdays
- Fridays
- Saturdays
- Sundays
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

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Request Contact

New Member

Demographic Information

Contact Preferences

Consent Form