Check-In/Drop-In/First Time VisitIf you are attending a recovery group, event, center resource, or training, select Check-In.Program*Recovery Community CenterRequest ContactPlease provide the following information and we will get back to you shortly.HiddenSection BreakAre 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* Recovery Group Recovery Special Event Center Resource Non-Participants can not check in for one-on-one sessions.HiddenI am attending-* Recovery Group Recovery Special Event Recovery Coaching (One-On-One) Center Resource Training Please fill our New Member form below if you are not a member! OR change to check-in anonymously.I am attending:* Recovery Group Recovery Special Event Recovery Coaching (One-On-One) Center Resource Training Please fill our New Member form below if you are not a member! OR change to check-in anonymously.Recovery Group* All Recovery NA AA MARA Celebrate Recovery Smart Recovery Al-Anon Hope Rising Hope Rising Teen Court Nami Training Type* Architects of Hope Peer Support Specialist WRAP Celebrate Recovery Narcan Community Training Event Type* Opioid Overdose Awareness Day We Are Hope Week Center Resource* Vocational Services Case Navigation Volunteer Peer Support Alcohol/Drug Assessment Parenting Bike Program Food Pantry Please briefly describe what you would like to discuss*HiddenRequest 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 Email* If you don't have an email address, please input "no@email.com".Phone*Please enter (000)-000-0000 if you do not have a phone numberAddress* 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 Demographic InformationDate of Birth* MM slash DD slash YYYY 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 Other Race: Ethnicity Hispanic Not Hispanic Other Other Ethnicity: Gender (Select all that apply):* Male Female Nonbinary Transgender Prefer to Self-describe Gender: 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 PreferencesI am interested in:* Recovery Coaching Telephonic Recovery Supports Both Telephonic and Recovery Coaching 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 aboveBest Days to Call: Select All Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Best Time to Call Morning Afternoon Evening Anytime