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.This field is hidden when viewing the formSite*Hope United - Tyler's Redemption PlaceThis field is hidden when viewing the formSection BreakAre you:* Checking-In Leaving a Message (Existing Guest) Have you registered as a Guest 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 visitor?* Yes No Visitor Name*You may enter your first name, a nickname or Anonymous if you do not want to give your full name.Visitor PhoneIf you do not have or do not with to leave a phone number, please enter 000-000-0000.Visitor 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 guest form. I am attending:* Meetings Events and Activities Drop In Training Wellness Volunteer I am attending:* Meetings Events and Activities Drop In Training Wellness Volunteer Meetings* Steps to Serenity AA TRP Midday Group AA Drop the Rock Adult Children of Alcoholics and Dysfunctional Families Label Free Addiction No Matter What AA Mixed Bag AA Questions and Answers AA Smart Recovery Hope Arise The Shadow Project Mentoring The Well Loving with Grace Veterans in Recovery Events and Activities* Game Night Chess Club Pour Paint Ray of Hope Art Therapy Journaling Financial Bonfire Movie Night Sports Watch Party Rental Event Cooking Class Other Drop in* Peer Support/Resources Virtual Reality Virtual Reality Veterans Ohio Guidestone 360 Coffee at the Cabin Library Pool Room/Games Coffee/Connect Family Support one-on-one Training Type* Peer Training Trauma Training Wellness* Gym Sauna/Cold Plunge Yoga Cardio Drumming Meditation Sound Bath Salt Cave Body by Benny walk/run Breath work Veterans Workout Volunteer* Hope United Volunteer Community Service 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 Guest Interested in becoming a Guest 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 GuestPlease create your new guest 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 This field is hidden when viewing the formReason for Referral Select All Housing Employment Education Connection to treatment Connection to recovery community Recovery support Probation Overdose Co-occurring Multiple treatment episodes Other This field is hidden when viewing the formReason 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:Orientation/Identity* Straight/Heterosexual Gay/Lesbian Bisexual Queer Other Refused Orientation/Identity, if Other:Veteran Status* Not a Veteran Veteran Refused This field is hidden when viewing the formPrimary Language English Spanish French German Arabic Cantonese Hindi Korean Mandarin Russian Somali Samoan Tagalog Tongan Vietnamese ASL Other Refused This field is hidden when viewing the formDo you have health insurance? No Yes Unknown This field is hidden when viewing the formWhere do you live? Housed Unhoused Shelter Recovery Residence Residential Treatment Institution Halfway House Other Refused This field is hidden when viewing the formDescribe your living situation, if Other:This field is hidden when viewing the formPlease 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 This field is hidden when viewing the formRecovery Path, if Other:This field is hidden when viewing the formCOVID-19 Vaccine Status Fully Vaccinated Partially Vaccinated Unvaccinated This field is hidden when viewing the formContact PreferencesThis field is hidden when viewing the formI 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) This field is hidden when viewing the formConsent 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