Kiosk Dee's Place Form

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.

Site*

Request Contact

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

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Section Break

Are you:*

Checking-In
Dropping-In (Existing Member)
First Time Visit

Would you like to remain Anonymous?*

Yes
No

Name*

First Last

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.

I am anonymously attending*

Center Resource

Non-Participants can not check in for one-on-one sessions.

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I am attending-*

Recovery Group
Recovery Special Event
Center Resource

Please fill our New Member form below if you are not a member! OR change to check-in anonymously.

I am attending:*

Recovery Coaching (One-On-One)
Center Resource
Training

Recovery Group*

Group 1
Group 2
Group 3

Training Type*

Training TBD

Event Type*

Event 1
Event 2

Center Resource*

Peer Recovery Support Services

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

Email*

If you don't have an email address, please input "no@email.com".

Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about us?*

Friend/Family
Treatment Provider
Probation officer
Emergency Department

Reason for Referral

Demographic Information

Date of Birth*

Race*

White
Hispanic, Latino, or Spanish Origin
Black or African American
Middle Eastern or North African
American Indian or Alaska Native –
Asian –Native Hawaiian or Other Pacific Islander
More than one race
Other

Ethnicity

Hispanic
Not Hispanic
Other

Gender (select all the apply)*

Male
Female
Nonbinary
Transgender
Prefer to Self-Describe

Gender:

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Gender*

Male
Female
Other
Nonbinary

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Do you identify as Transgender*

No
Yes
Prefer not to answer

Highest Level of Education

Less than HS
HS grad/GED
Some college
Technical School/2-yr degree
4-yr degree (BS/BA)
Graduate degree (Masters or doctorate)
Don't Know
Refused
Not Applicable

COVID-19 Vaccine Status

Fully Vaccinated
Partially Vaccinated
Unvaccinated

COVID-19 Vaccine Willingness

Currently Vaccinated
Wait and See
Only When Required
Definitely Not

Contact Preferences

I am interested in:*

Recovery Coaching
Telephonic Recovery Supports
Both Telephonic and In-person Recovery Services

Phone*

Please enter (000)-000-0000 if you do not have a phone number

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

Best Days to Call:

Select All
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

Best Time to Call

Morning
Afternoon
Evening
Anytime