Kiosk Hope United Form

Check-In/Leave a Message

If 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.

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Site*

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Section Break

Are 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 Phone

If 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:*

Recovery Group
Events and Activities
Recovery Coaching (One-On-One)
Drop In
Training
Wellness
Volunteer

I am attending:*

Recovery Group*

Events and Activities*

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*

Volunteer*

Hope United Volunteer
Community Service

Please briefly describe what you would like to discuss*

Request Contact

Please 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 Guest

Please create your new guest record.

Name*

First Last

Phone*

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

Email*

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

Address*

Street Address Address Line 2 City State ZIP Code

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Reason for Referral

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Reason for Referral, if Other:

Demographic Information

Date of Birth*

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

Primary Language*

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Do you have health insurance?

No
Yes
Unknown

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Where do you live?

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Describe your living situation, if Other:

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Please select which recovery path(s) you use.

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Recovery Path, if Other:

COVID-19 Vaccine Status

Fully Vaccinated
Partially Vaccinated
Unvaccinated

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Contact Preferences

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I 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)

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Consent Form

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