Kiosk Landmark Form

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Check-In
If you are attending something scheduled: select Check-In. If you are coming to just hang out: select Drop-In.
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Site*
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Section Break
Are you:*
- Checking-In for Appointment or Activity
- Dropping-In to Hang Out
Have you registered as a Member or 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.
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Would you like to check in as a guest?*
- Yes
- No
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Guest Name*
You may enter your first name, a nickname or Anonymous if you do not want to give your full name.
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Guest Phone*
If you do not have or do not with to leave a phone number, please enter 000-000-0000.
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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.
Please click here to fill out the First Time Guest form.
I am attending:*
- Recovery Group
- Recovery Special Event
- Center Resource
- Training
- Other Appointment
I am attending:*
- Recovery Group
- Recovery Special Event
- Center Resource
Recovery Group*
- All Recovery
- Testimony Tuesday
- Parenting Class
- Anger Management
- CoDA
- NAMI Family Support Group
- NAMI Connections
- Abundant Life Recovery Meal
- Abundant Life Recovery Meeting
- Gardening
- Life Skills
- Open Process Group
- Crafting Class
Event Type*
- N/A
Center Resource*
- Employment Services
- Housing Services
- Sober Living Resources
- Substance Use Support
- Food Resources
- Clothing/Hygiene Resources
- Transportation Resources
- Criminal Justice Navigation
- Mental Health Support
Training Type*
- N/A
Other*
- Peer Support Session
- Appointment with P.O.
- Therapy Appointment
- Community Service
- Using a Meeting Room
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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 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 Member or First Time Guest
DO NOT USE ANY SEMI-COLONS (;) TO FILL OUT THIS FORM!
Name*
First Last
Preferred Name (If Different than First Name)
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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How did you hear about us?
- Friend/Family
- Treatment Provider
- Probation officer
- Emergency Department
- Recovery House
- Problem Solving Court
Demographic Information
Date 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:
Veteran?*
- Not a Veteran
- Veteran
Drug of Choice:
Intake Information
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:
Referred From*
Referral Contact*
Do you have health insurance?*
- No
- Yes
- Unknown
Insurance Type*
Case Load*
Substance Use
Do you have a history of substance use?*
- Yes
- No
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Drug of Choice*
Drug(s) of Choice*
- Alcohol
- Amphetamines
- Benzodiazepines
- Caffeine
- Cocaine/Crack
- Fentanyl
- Hallucinogens/Psychedelics
- Heroin
- Inhalants
- Kratom
- Marijuana/Hashish/Synthetic Cannabis
- Methamphetamine
- Opiates
- Other Substances
- Tobacco/Nicotine
- Xylazine
- None
Other Drug(s) of Choice*
Approximately how long have you been using this substance?*
Interested in finding treatment?*
- Yes
- No
Interested in sober living?*
- Yes
- No
Interested in Medicated Assisted Treatment?*
- Yes
- No
Physical Health
List current dental needs:
List current vision care needs:
List details pertaining to any open wounds or injuries requiring attention:
Any concerns about STDs?
Mental Health
Do you consider yourself to have a mental health condition?*
- Yes
- No
Mental Health Condition*
Have you had suicidal thoughts in the past or present?*
- Yes
- No
Have you ever been hospitalized for your mental health?*
- Yes
- No
When you're going through a mental health episode, what are your symptoms?
Are you currently taking medication for your mental health?*
- Yes
- No
What medications are you currently taking?
Any medication allergies?
Do you currently receive services or treatment for a mental health condition?*
- Yes
- No
Any other Relevant Information for Mental Health
Basic Needs
Do you have a birth certificate?*
- Yes
- No
Do you have a Social Security Card?*
- Yes
- No
Do you have an ID?*
- Yes
- No
Criminal Justice Involvment
Have you been incarcerated?*
- Yes
- No
Current Charges:
County or Counties Charged:
Attorney Name
Attorney Contact Info
Other Criminal Justice Relevant Details:
Are you on probation or parole?*
- Yes
- No
Officers name?*
Housing
Do you have needs concerning a current housing situation?*
- Yes
- No
Where do you live?*
- Housed
- Unhoused
- Shelter
- Recovery Residence
- Residential Treatment
- Institution
- Halfway House
- Other
- Refused
If Other, Describe your living situation
Please list relevant housing information:
Transportation
Do you have reliable transportation?*
- Yes
- No
Primary mode of transportation*
Family
Do you have parenting, childcare, or other family needs?*
- Yes
- No
What are your main family needs?
Employment
Employment Status*
Where are you employed?
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Annual Income Range
- No income
- Under $10,000
- Between $10,001 and $20,000
- Between $20,001 and $30,000
- Between $30,001 and $40,000
- Between $40,001 and $50,000
- Between $50,001 and $60,000
- Between $60,001 and $70,000
- Between $70,001 and $80,000
- Between $80,001 and $100,000
- Above $100,000
Job Seeking*
- Yes
- No
Please list job interests here:*
Academic
What is the highest grade you completed in school?*
What are your academic goals?
Resources
What community resources are you already using?
Personal Strengths - Staff will work to identify the strengths they have noticed during the assessment, highlighting resilience.
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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:
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COVID-19 Vaccine Status
- Fully Vaccinated
- Partially Vaccinated
- Unvaccinated
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Contact Preferences
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

Check-In

Section Break

Request Contact

New Member or First Time Guest

Demographic Information

Intake Information

Substance Use

Physical Health

Mental Health

Basic Needs

Criminal Justice Involvment

Housing

Transportation

Family

Employment

Academic

Resources

Contact Preferences

Consent Form