HOPE RISING Step 1 of 3 33% Check-In/Drop-In/First Time VisitIf you are attending a recovery group, event, center resource, or training, select Check-In.Program*Hope RisingRequest ContactPlease provide the following information and we will get back to you shortly.This field is hidden when viewing the formSection 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 Please go back and fill out the New Member form prior to checking in! OR change to check-in anonymously.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.This field is hidden when viewing the formI 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 Recovery Group* Hope Rising Diversion Hope Rising Teen Court Hope Rising Course Cycles of Hope Triple P Training Type* Architects of Hope TOT Architects of Hope Event Type* Henderson County Youth Council 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*This field is hidden when viewing the formRequest 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 Hope Rising 109 Florence St Hendersonville, NC 28792 Juvenile Consent Form I acknowledge participation in the Hope Rising Diversion Program. This program offers alternatives to the juvenile and justice systems by blending education, accountability, family focus, support and recovery into one program. Hope Rising is a voluntary diversion program that has been explained to me. I understand that I have the right to seek legal counsel. I understand that if I volunteer to participate in the program but fail to appear at an intake appointment and then my assigned court date, my case will be referred to the Twenty-Ninth District Juvenile Court Services to pursue criminal prosecution against me, if referred by the Department of Juvenile Justice. I understand that I am required to participate in Hope Rising group classes and activities, and that I am required to be on time to all classes. Consent* Juvenile Hope Rising Diversion Program ConsentParent/Guardian Consent Form Because your child meets preliminary eligibility criteria, she/he is being offered an alternative to traditional juvenile justice procedures. The intent of the Hope Rising diversion program is to redirect your child toward positive, lawful behavior. Participation is voluntary. Should you allow your child to choose this alternative diversion program, you and your child must attend an “intake” appointment with the Hope Rising Coordinator. If your child fails to appear or fails to complete his/her program requirements, your child will be referred to the Twenty-Ninth District Juvenile Court Services to pursue criminal prosecution. Your child must not miss more than 2 of the 12 required classes for this program. You can choose not to allow your child to participate. Should you decide to withdraw your child from this program, you may do so. Consent* Parental Hope Rising Diversion Program Consent Juvenile’s Signature*Parent's Signature*Parent's Name*Date* MM slash DD slash YYYY