• AHR Sponsor Ticket
  • AHR Sponsorship and Table Purchase
  • ARCO Leadership Summit 2019 Agenda
  • ARCO LS 2019 Session Detail Submission
  • ARCO Session Evaluation
  • Atlantic OHH
  • Beta Testing Feedback
  • Beyond Brink Full Consent Test
  • Burlington OHH
  • C4R Check-In
  • C4R Contact
  • C4R Member Registration
  • clr
  • Communities For Recovery
  • CTO Assessment
  • Donate
  • F&V Contract
  • F&V Support Request
  • First Time Visit
  • Focus RWC
  • Focus RWC Activity Check-in
  • Focus RWC First Time Visit
  • Focus RWC Meeting Attendance
  • Focus RWC Member Check-in
  • Focus RWC New Member
  • Focus RWC Volunteer Log
  • Illinois Stigma
  • Internal Survey
  • Kiosk 2.0 Template Form
  • Kiosk A Way Forward
  • Kiosk A Way Forward Form
  • Kiosk AICDAC
  • Kiosk AICDAC Form
  • Kiosk Amethyst Recovery
  • Kiosk Amethyst Recovery Form
  • Kiosk Anderson
  • Kiosk Anderson Form
  • Kiosk APAA
  • Kiosk APAA Form
  • Kiosk ARCH
  • Kiosk ARCH Confirmation
  • Kiosk ARCH Form
  • Kiosk ARCH Visitor
  • Kiosk BARN
  • Kiosk BARN Confirmation
  • Kiosk BARN Form
  • Kiosk BARN Visitor
  • Kiosk Beyond Brink
  • Kiosk Beyond Brink Consent
  • Kiosk Beyond Brink Form
  • Kiosk BRCC
  • Kiosk BRCC Confirmation
  • Kiosk BRCC Form
  • Kiosk BRCC Visitor
  • Kiosk Cape Regional
  • Kiosk Cape Regional Form
  • Kiosk Chicago RCC
  • Kiosk Chicago RCC Form
  • Kiosk Communities for Recovery Form
  • Kiosk Communities for Recovery Spanish
  • Kiosk Communities for Recovery Testing
  • Kiosk Courage Center
  • Kiosk Courage Form
  • Kiosk CRA
  • Kiosk CRA Form
  • Kiosk Dee’s Place
  • Kiosk Dee’s Place Form
  • Kiosk DownEast Calais
  • Kiosk DownEast Calais Confirmation
  • Kiosk DownEast Calais Form
  • Kiosk DownEast Calais Visitor
  • Kiosk DownEast Machias
  • Kiosk DownEast Machias Confirmation
  • Kiosk DownEast Machias Form
  • Kiosk DownEast Machias Visitor
  • Kiosk FAVOR Upstate
  • Kiosk FAVOR Upstate Form
  • Kiosk FAVOR Western PA
  • Kiosk FAVOR Western PA Form
  • Kiosk Greenville
  • Kiosk Greenville Form
  • Kiosk Home 2.0 Template
  • Kiosk Home MOAR
  • Kiosk Home Template
  • Kiosk Hope Coalition
  • Kiosk Hope Coalition Form
  • Kiosk Hope Rising
  • Kiosk Hope Rising Form
  • Kiosk Hope United
  • Kiosk Hope United Form
  • Kiosk Johnson City
  • Kiosk Johnson City Form
  • Kiosk Kentucky River District Health
  • Kiosk Kentucky River District Health Form
  • Kiosk LCRCC
  • Kiosk LCRCC Confirmation
  • Kiosk LCRCC Form
  • Kiosk LCRCC Visitor
  • Kiosk Life Align
  • Kiosk Life Align Form
  • Kiosk Loudoun Serenity
  • Kiosk Loudoun Serenity Form
  • Kiosk LRRC
  • Kiosk LRRC Confirmation
  • Kiosk LRRC Form
  • Kiosk LRRC Visitor
  • Kiosk MOAR
  • Kiosk Mountain Top
  • Kiosk Mountain Top Form
  • Kiosk MyPIR
  • Kiosk MyPIR Form
  • Kiosk NARSS
  • Kiosk NARSS Form
  • Kiosk Never Alone
  • Kiosk Never Alone Form
  • Kiosk New Way
  • Kiosk New Way Form
  • Kiosk NIRCO
  • Kiosk NIRCO Form
  • Kiosk Oconee
  • Kiosk Oconee Form
  • Kiosk Pickens
  • Kiosk Pickens Form
  • Kiosk PRCC
  • Kiosk PRCC Confirmation
  • Kiosk PRCC Form
  • Kiosk PRCC Visitor
  • Kiosk R2RC
  • Kiosk R2RC Confirmation
  • Kiosk R2RC Form
  • Kiosk R2RC Visitor
  • Kiosk RC Network
  • Kiosk RC Network Form
  • Kiosk Reality Check
  • Kiosk Reality Check Form
  • Kiosk Recovery Beyond
  • Kiosk Recovery Beyond Form
  • Kiosk Recovery Beyond Landing
  • Kiosk RioGrande
  • Kiosk RioGrande Form
  • Kiosk RioGrande2
  • Kiosk Rise Up Recovery
  • Kiosk Rise Up Recovery Confirmation
  • Kiosk Rural Recovery
  • Kiosk Rural Recovery Form
  • Kiosk Sage’s Army
  • Kiosk Sage’s Army 2
  • Kiosk Sage’s Army 2 Form
  • Kiosk Sage’s Army Form
  • Kiosk SALC
  • Kiosk SALC Confirmation
  • Kiosk SALC Form
  • Kiosk SALC Visitor
  • Kiosk Savannah
  • Kiosk Savannah Form
  • Kiosk Set Up Information
  • Kiosk Spartanburg
  • Kiosk Spartanburg Form
  • Kiosk SRCC
  • Kiosk SRCC Confirmation
  • Kiosk SRCC Form
  • Kiosk SRCC Visitor
  • Kiosk Summit Recovery Hub
  • Kiosk Summit Recovery Hub Form
  • Kiosk Template Form
  • Kiosk Trilogy
  • Kiosk Trilogy Form
  • Kiosk Turning Point
  • Kiosk Turning Point Form
  • Kiosk Turning Point of Chittenden County
  • Kiosk Turning Point of Chittenden County Form
  • Kiosk Wakeup
  • Kiosk Wakeup Form
  • Kiosk Will Work for Recovery
  • Kiosk Will Work for Recovery Form
  • LRCC
  • LRCC Activity Check-in
  • LRCC First Time Visit
  • LRCC Meeting Attendance
  • LRCC Member Check-in
  • LRCC New Member
  • LRCC Volunteer Log
  • Mercer OHH
  • NJ CARS Forms
  • NJ RISE OHH
  • NJ-CARS Media Consent
  • OHH Activity
  • OHH Kiosk RH
  • OLDOrg Kiosk
  • Onboarding Feedback
  • Org Kiosk Check-In
  • Org Kiosk Contact
  • Org Kiosk New Member
  • Org Name Kiosk
  • PCAC Kiosk
  • Peer Coach Academy Kiosk
  • PIK Consent
  • PIK Consent 2.0
  • Prevention TRS
  • Privacy Policy
  • RCCF 2.0
  • RCCF Form
  • RCCF1 Form
  • RCCF2 Form
  • RDP Agreements
  • RDP Feedback
  • RDP LITE – COVID SURVEY
  • RDP Survey
  • Recovery Connection
  • RLS/AHR Sponsorship Leads
  • RMC NJ-CARS
  • SCRW Kiosk
  • Serenity House of Flint
  • SHOF Activity Check-in
  • SHOF BARC-10
  • SHOF First Time Visit
  • SHOF HH Study
  • SHOF Meeting Attendance
  • SHOF Member Check-in
  • SHOF New Member
  • SHOF Volunteer
  • Signature
  • Springs Recovery Connection
  • SRC Event/Training Attendance
  • SRC Meeting Attendance
  • SRC Member Check-in
  • SRC Member Registration
  • Sunrise Community for Recovery Wellness Kiosk
  • Tech Onobarding
  • Technical Assistance Feedback
  • This is a test.
  • Thriving U Kiosk
  • Thriving United Kiosk
  • TU Check-In
  • TU Contact Request
  • TU Participant
  • Turning Point 2
  • Turning Point 2 Form
  • USARA
  • USARA Activity Check-in
  • USARA ARCHES
  • USARA Meeting Attendance
  • USARA Member Check-in
  • USARA Volunteer Log
  • Website Feedback
  • Wilkes Recovery Revolution Kiosk
  • Will Work For Recovery Consent Form
  • WRR Kiosk
  • WW4R Consent Form Page
  • WW4R Consent Page
  • Uncategorized
Faces & Voices of Recovery Data Hub

Step 1 of 11

9%
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form
  • This field is hidden when viewing the form

    Participant Information Form

    Please create your new participant record.
  • MM slash DD slash YYYY
  • If current address does not exist please use NA
  • 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".
  • MM slash DD slash YYYY

  • Substance Use Information

    Please select any that apply

  • Demographic Information

  • Healthcare

  • Substance Use

  • Check all that apply.

  • Mental Health

  • Legal History

  • Communication

  • In addition to face to face communication, I agree that Communities for Recovery may communicate with me using the following methods. I understand that these methods of communication may not be confidential and can be intercepted and possibly read or heard by other people.
  • Please check all that apply.

  • Forms to be Completed

    Please select which form(s) need to be completed.

  • Peer Recovery Support Participant Enrollment Form

  • The Peer Recovery Support Program provided by Communities for Recovery is a partnership in which a person with experience in recovery supports another person to establish or enhance their recovery through social support and recovery wellness planning.


    Social Support

    • Emotional support – providing encouragement

    • Informational support – sharing knowledge or resources

    • Instrumental support – concrete assistance like rides, resume writing, etc.

    • Affiliational support – creating a sense of belonging


  • Wellness Recovery Planning

    • Goals – a person’s needs, hopes, and dreams

    • Challenges – the obstacles, barriers, and stigma of addiction

    • Strengths – the assets, relationships, and capital which a person can leverage to enhance their life

    • Plans – the action steps a person can take to achieve their goals, overcome challenges, and build a health


  • This enrollment process is the agreement to work together and make contact on a regular basis. This can be a meeting in-person or by other means such as phone, text, email, etc. If you cannot be reached for 30 days then your enrollment may become inactive. However you are welcome to re-engage our services at any time.

  • Peer Recovery Support Services Informed Consent

  • I understand that Communities for Recovery makes every effort to ensure confidentiality is maintained with respect to all aspects of information divulged when someone is participating in individualized peer support services. There are strict policies and procedures in place to protect the confidentiality of those enrolled in services.


    Communities for Recovery takes the following steps:

    •Keeping files in locked cabinets, and limiting who may access these files;

    •Providing all staff, including Peer Specialists a n d Volunteers with a comprehensive training that outlines the importance of confidentiality and privacy;

    •Maintaining an ethical standard held by all staff and volunteers that prohibits any breach of confidentiality, and prohibits gossip;

    •Ensuring that all staff and volunteers adhere to the policy outlining “Scope of Service,” which prohibits offering any services beyond the scope of the staff and volunteer’s expertise;

    •Making the appropriate referrals if there is a need of professional services beyond the scope of service provided through Communities for Recovery


    As a Communities for Recovery program participant, I agree to the following exceptions to confidentiality, in which case information may be disclosed to the appropriate authorities, agencies, and/or individuals as mandated by state and or federal laws:


    •If a Peer Specialist, Volunteer, or a staff member has reason to believe that you may harm yourself and/or others

    •If a Peer Specialist, Volunteer, or a staff member has reason to believe that you are involved in or have knowledge of abuse, neglect, and/or neglect or a child, or abuse, neglect, and/or exploitation of a person who is elderly or has a disability

    •Ordered disclosure by state or federal courts


    In addition, CforR requires disclosure of information in the following circumstances:


    •A signed release form granting permission to designated third parties to received information as needed

    •Discussion of your file for Communities for Recovery supervisory and/or training purposes


    I understand that if I have any questions or concerns about my participation in this project, I may contact the Executive Director, Darrin Acker.

  • Participant Rights

  • •You have the right to accept or refuse services.

    •If you agree to services you have the right to change your mind at any time.

    •You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your personal needs.

    •You have the right to be free from abuse, neglect, and exploitation.

    •You have the right to be treated with dignity and respect.

    •You have the right to appropriate services that meet your needs.

    •You have the right to be told before receiving services, in a language that you can understand, about the program's rules and regulations.

    •You have the right to a service plan designed to meet your needs, and you have the right to take part in developing that plan.

    •You have the right to meet with staff to review and update the plan as needed.

    •You have the right to refuse to take part in research without affecting your services.

    •You have the right to have information about you kept private and to be told about the times when the information can be released without your permission.

    •Your services are paid for in full and there are no additional charges to you.

    •You have the right to receive an explanation of your services or your rights if you have questions while you are receiving services.

    •You have the right to make a verbal or written complaint and receive a response from the Program Manager within a reasonable amount of time.

    •You have the right to complain directly to the Department of State Health Services by contacting‐
    Texas Health and Human Services Commission
    Ombudsman for Behavioral Health
    P.O. Box 13247
    Austin, TX 78711‐3247
    1 (800) 252‐8154
    (If needed, call the toll‐free Relay Texas service at 7‐1‐1 or 800‐735‐2989.)

    •You have the right to get a copy of these rights before you are accepted into the program.

    •You have the right to have your rights explained to you in simple terms, in a way you can understand, prior to receiving recovery services.

    •You have the right not to be restrained or placed in a locked room.

  • Consent to Provide Checkup Information

  • Periodically, we will be checking in with you to see how things are going. We will be checking in with you at least once every three months, whether or not you are still actively participating in our programs. When we check in with you, we will be asking questions about your life similar to those we just asked as you enrolled in our program.

    If we cannot reach you directly, are there any friends, family members or other contacts you would allow us to speak with about how you are doing in the areas listed above?

    Other people I authorize to provide information on my recovery and life domains:

  • For the section below, please enter NA in each field if it is not applicable. For phone number, enter 000-000-0000 if not applicable. For email, enter no@email.com if not applicable.


  • I____________________________________ hereby authorize a representative of Communities for Recovery if they cannot contact me directly, to contact the individuals named above in order to obtain information about my progress in recovery and life domains.

    Date of Expiration: The date, event, or condition upon which this consent will expire without my expressed revocation shall be ____________ (16 months from today), which is of duration no longer than that reasonable necessary to effectuate the purpose for which this consent is given.

  • Please enter the date when this consent will expire (16 months from today unless otherwise specified).
    MM slash DD slash YYYY

  • I understand that I may revoke at any time expect to the extent that action has been taken in reliance thereon. I further understand that such disclosure shall be limited to information necessary in the light of the need or purpose for the disclosure. I further understand that Title 21 U.S.C. 1175 AND 42 C.F.R., Part 2 require that information released pursuant to this consent remains subject to the restriction that it not be further disclosed or used for any purpose other than as stated herein without my specific written consent, or as otherwise permitted by such Federal law and regulations.

  • Evaluation Consent Form

  • Recovery support services at Communities for Recovery (CforR) are provided at no cost to participants. In order to fund and develop the most effective services, CforR must gather and evaluate data from its programs. This data is obtained from service records and surveys conducted during the intake and approximately every 3 months following enrollment. The data is used by both CforR and its supporting agencies such as Health and Human Services Commission (HHSC) and the Substance Abuse and Mental Health Services Administration (SAMHSA). Participation in these surveys empowers our partners to shape the way services are delivered at CforR and throughout our area. You have the right to refuse to take part in research/evaluations and refusal will not exclude you from your services.

    Benefits from participating in the evaluation include:
    •Sharing your experience and progress to help other people in recovery.
    •Monitoring and improving services in the Austin, Travis county area.
    •Advocating for Peer Support Services.

    Risks from participating in the evaluation include:
    •Breach of confidentiality of data.
    •Discomfort in answering some questions.

    Protections from potential risks include:
    •The data protections described in the consent to participate.
    •Your ability to refuse to answer any questions and stop the interview at any time.

  • I understand that if I have any questions or concerns about my participation in the evaluation, I may contact the Executive Director, Darrin Acker.

  • Authorization to Release Information

  • I, _________________ by signing this Authorization, am giving permission to use and disclose information about me as described below. I authorize the following entity to disclose my health information in accordance with this Authorization:

    Communities for Recovery

    Individual or Agency Receiving My Information
    I authorize use by or disclosure of my recovery information to the following entity:

  • Enter NA if not applicable.
  • Enter NA if not applicable.
  • If no phone number, enter 000-000-0000.
  • If no email, enter no@email.com.
  • If no FAX number, enter 000-000-0000.

  • Expiration Date
    This Authorization expires on the following date if not revoked in writing earlier:

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Purpose of Authorization
    I authorize the use or disclosure of my recovery information as set forth in this Authorization for the following purposes:

  • Is party other than participant signing the authorization?
  • The person listed below is legally authorized to use or disclose the health information for the participant:
  • Enter NA in both fields if not applicable.

  • I understand that my eligibility for services cannot be conditioned upon my signing this Authorization; however, services to be paid for by any third party are conditioned upon my signing this Authorization for disclosure to the third party when Authorization is required by law or for payment purposes. I am not guaranteed services on the basis of this Authorization.

    My health information may be protected under federal and state laws and may not be disclosed without my signed Authorization, unless otherwise provided for by state or federal law. Even if I refuse to sign this Authorization, my health information may be used or disclosed without this Authorization when allowed or required by law. Information disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected under HIPAA.

    I also understand that I may revoke this Authorization in writing to this provider at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires in accordance with the conditions specified in this document. This Authorization cannot be revoked if the use or disclosure is required for payment to this provider for services provided in reliance on this Authorization.

  • Austin / Travis County Homeless Management Information System Data Sharing Policy and Release of Information (ROI)

  • Please enter NA if not used.

  • Agency Completing Form: Communities for Recovery

    This agency collects information about people who ask about our homeless services. When we meet with you, we will ask you for information about you and your family. We will put the information you give us into a computer program called WellSky ServicePoint (or "HMIS").

    Austin / Travis County HMIS data is all stored in one computer system. Your information will be shared with all agencies that use our system (all "HMIS Agencies") to help you get services more quickly and easily. A list of all current HMIS Agencies is on the next page of this form, and you can ask for a new copy at any time.

    The Personal Information we share may include:

    • Personal Identifying Information (such as name, social security number, and date of birth)
    • Who is in your household
    • Job history
    • Military history
    • Living situation and housing history
    • Educational background
    • Demographic information (such as race, gender, and ethnicity)
    • Your income and income sources
    • Services you request or receive
    • If you are experiencing homelessness or not
    • Reasons for seeking services
    • Self-reported health needs

    You can refuse to answer any question at any time, including questions about the things listed above. You will never be denied help because you did not answer a question, unless we need to know that answer to know if you are eligible for a service.

    We will not store or share treatment records about Mental Health, HIV/AIDS, or Drug, Alcohol, or Substance Abuse Treatment unless you give us specific permission.

    We may also share some of your information from HMIS with agencies that do not use our HMIS system ("Outside Agencies") for different summary reports about homelessness. Personal Information that could be used to tell who you are will only be put in those reports if we have your written permission, or if the law lets us or requires us to share that information without your permission.


  • Please initial here to show that you have read and understand the rules above.

  • Consent for Release of Personal Information
    In addition to the information sharing above, you can also choose:

    • To let HMIS Agencies share and discuss your Personal Information outside of the computer system to help give you services;
    • To let HMIS Agencies share your Personal Identifying Information with Outside Agencies for research, reporting, and coordinating services; and
    • To let HMIS Agencies put any treatment records about Mental Health, HIV/AIDS, or Drug, Alcohol, or Substance Abuse Treatment into our computer system as part of your Personal Information.
    Please think about the information below before making your decisions:
    • Personal Information that can be used to tell who you are (Personal Identifying Information) will only be shared with Outside Agencies with your permission, or when the law lets us share that information without your permission.
    • If you let us put any treatment records related to Mental Health, HIV/AIDS, or Drug, Alcohol, or Substance Abuse Treatment into our computer system, we will share that information just like the rest of your Personal Information.
    • The current list of HMIS Agencies is below. Any agency not on that list is considered an Outside Agency. Other agencies may join this list in the future and share your information just like the current HMIS Agencies. You may ask for an updated list of the HMIS Agencies from any HMIS Agency at any time.
    • Some of your Personal Information may be protected by additional state and federal privacy laws. Agencies that must follow these laws may need additional permission to collect or share some of your information.
    • Once we share your information with an Outside Agency, that agency can sometimes share it with other Outside Agencies, if the law says they can.
    • This consent is voluntary. You will not be denied services if you decline to sign this consent form.

    Current Austin / Travis County HMIS Agencies:

    • A New Entry
    • Any Baby Can
    • Caritas of Austin
    • Casa Marianella
    • Capital Metropolitan Transportation Authority
    • Catholic Charities of Central Texas
    • City of Austin APL, CDU, DACC, EMS, CIT, APH
    • CommUnity Care
    • Ending Community Homelessness Coalition (ECHO)
    • Family Eldercare
    • First Baptist Church Austin
    • Foundation Communities
    • Foundation for the Homeless
    • Front Steps
    • Goodwill Industries of Central Texas
    • Green Doors
    • Housing Authority - City (HACA)
    • Housing Authority of Travis County (HATC)
    • Integral Care
    • LifeWorks
    • LINC Austin
    • Maximizing Hope
    • Meals on Wheels and More
    • Mobile Loaves and Fishes
    • Mosaic Church Austin
    • Refugee Services of Texas
    • SAFE Alliance
    • Saint Louise House
    • Sunrise Homeless Navigation Center
    • The Salvation Army
    • Sobering Center
    • The Other Ones Foundation
    • Travis County - Health & Human Services & Veteran Services
    • Travis County - Mental Health Public Defenders
    • Travis County Public Defender’s Office
    • Travis County Sheriff’s Department
    • Trinity Center
    • U.S. Department of Veteran Affairs
    • Vivent Health

    Optional Agencies Section

    Please choose one:

    Yes, all Austin/Travis County HMIS Agencies may share and discuss Personal Information about me and my family outside of the computer system to help give us services. They may also share that information with Outside Agencies for research, reporting and coordinating services.

    Permission to share your information will last for seven years from the date you sign this form. You can cancel this permission at any time by sending a written letter to the agency where you filled out this form. It may take up to three business days to process the cancellation letter.

    No, I do not want HMIS Agencies to share and discuss my Personal Information outside of the computer system. I also do not want information that can be used to tell who I am to be part of any outside reports or research. HMIS Agencies may only share information in the computer system for questions I choose to answer.



  • If you chose NO above, you can still choose to let HMIS Agencies share and discuss your Personal Information with specific Outside Agencies or Individuals outside of the computer system to coordinate services. If you want to do that, please initial your choices below.

  • Enter NA if none.
  • Enter NA if not applicable.
  • Enter NA if not applicable.
  • Enter NA if not applicable.

  • Optional Treatment Records Section
    Please initial below if you would like to put treatment records about Mental Health, HIV/AIDS, or Drug, Alcohol, or Substance Abuse Treatment in our computer system as part of your Personal Information. We will share this sensitive health information for the record types you initial below:
  • If none selected, enter NA.
  • Enter NA if not applicable.
     
  • Select all that apply and initial below

  • Identity/Residency/Income Form

  • MM slash DD slash YYYY
  • Please enter your address. If you do not have an address, please enter NA in each field.

  • Proof of Identity

  • Copy of at least one form of government issued ID

  • Residency

  • Copy should be attached and the document must have an address that includes participant’s name.

  • Anyone funded by the City of Austin must be a confirmed Austin/Travis County Residency. The document must be current, pre-date program enrollment, & verified by City-approved website. Not needed for homelessness or if fleeing domestic violence.

    Austin GIS Jurisdictions Web Map (http://www.austintexas.gov/gis/JurisdictionsWebMap/)

    Travis County Appraisal District website (http://www.traviscad.org)

  • Confirmed Austin/Travis County Resident

  • Household Members and Household Income

  • Record all household members below. “Household Member” is defined as: 1) A person over the age of 18 who is living alone or with others who are not responsible for their support, 2) One or more persons living together who are wholly or partially legally responsible for the support of the other people in the household, 3)Two persons in a domestic partnership, or legal or common-law marriage, 4) One or both legal parents and their minor children, and 5) One or both adult caretakers of minors or person with a disability over the age of 18 and those minors or disabled persons.
  • List all members of your household, beginning with yourself
    Household Member First and Last NameAdult or Minor (type full response)Date of Birth (please enter as xx/xx/xxxxIncome (Yes or No)Gross Income of Last 30 days ($ amount)Documentation Type (from list below. If other, please specify) 
  • If no income, please enter 0.

  • Documentation Types for Gross Income of last 30 days: (For all adult household members)

    Dated within the current calendar year:

    • A - Pay Stubs
    • B - Employer Verification
    • C - Unemployment statements
    • D - Severance pay statements
    • E - TANF letter
    • F - Self-employment ledger
    • G - SSI/SSDI award letter
    • H - Pension statements
    • I - Worker’s compensation
    • J - Retirement income statement
    • K - Training stipend
    • L - Alimony
    • M - Other:
    • N - Self-Declaration of income

  • I certify that all the information and documentation provided by me in connection with my application is true and complete, and I understand that any misstatement, falsification, or omission of information may be grounds for refusal of services. I authorize the release of the information provided on this document to Communities for Recovery for the purpose of grant eligibility and reporting.

  • Media Consent & Release Form

  • I hereby grant Communities for Recovery the right to copyright and/or publish photographs, video, print, electronic, or any other media, statements, my image, voice and/or performance in whole or in part without compensation for purposes of: public education and information, illustration, promotion, art, editorial, or any other lawful purpose.

    I grant these rights for the use of news, education, art, the Internet and World Wide Web, and/or any other lawful purpose whatsoever for related CforR products and materials.

    I waive any right to inspect and/or approve any products which are developed by CforR.

    I also release CforR, their agents, and officers from any and all claims relating to/arising from the uses above.

    I understand that under no circumstances will I have any right to maintain any cause of action against CforR because of this agreement.

    This authorization is continuous and may only be withdrawn by my specific rescission of this authorization.

    I am of full legal age and have the right to sign this contract in my own name. If I am not of full legal age, my parent or guardian will sign on my behalf. I have read the above statements prior to signing this form and staff have addressed any of my questions.

    I fully understand the content of the agreement and enter into the Agreement knowingly and willingly. This consent and release is binding upon me, my heirs, and legal representatives.

  • Complete Forms with Signature

  • This signature is specifically for the Media Consent form if the person completing the form is a minor.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY