Return to Kiosk Home Page Check-In/Leave a MessageIf you are attending a recovery group, event, center resource, or training, select Check-In. If you are an existing member and would like to leave a message for staff, select Leave a Message.HiddenSite*FAVOR Western PAHiddenSection BreakAre you:* Checking-In Leaving a Message (Existing Member) 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* You may enter your first name, a nickname or Anonymous if you do not want to give your full name.Guest Phone*If you do not have or do not with to leave a phone number, please enter 000-000-0000.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 Training Recovery Group* Family Group All Recovery Spirituality Group Pathway Cafe Gym Therapy AHN Clinic Grief Group Kidz Krew Youth Group Event Type* Placeholder Center Resource* Food Bank Detox/Rehab Information Family Support Harm Reduction Supplies Distribution Training Type* CRS CPS Family Recovery Coach CPR/First Aid Please briefly describe what you would like to discuss*Request ContactPlease 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 MemberPlease create your new member record.Name* First Last Phone*Please enter (000)-000-0000 if you do not have a phone numberEmail* If you don't have an email address, please input "no@email.com".Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us? Friend/Family Treatment Provider Probation officer Emergency Department Reason for Referral* Select All 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 InformationDate of Birth* MM slash DD slash YYYY 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 Institution Halfway House 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: COVID-19 Vaccine Status Fully Vaccinated Partially Vaccinated Unvaccinated Contact PreferencesI 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 FormThe 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