Kiosk Loudoun Serenity Form

Check-In/Drop-In/First Time Visit

If you are attending a recovery group, event, center resource, or training, select Check-In. If you are here to see your Recovery Coach, select Drop-In.

Site*

Request Contact

Please provide the following information and we will get back to you shortly.

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Section Break

Are you:*

Checking-In
Dropping-In (Existing Member)

Would you like to remain Anonymous?*

Yes
No

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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

Non-Participants can not check in for one-on-one sessions.

I am attending:*

Recovery Group
Recovery Special Event
Recovery Coaching (One-On-One)
Training

Please click here to fill out the new member form.

Recovery Group*

Recovery Meeting
SUD Education
General Health & Wellness Education
Phased Fitness, Valerie Rider Session

Training Type*

REVIVE! Opioid Overdose and Naloxone Education
72-hour DBHDS Peer Recovery Specialist Certification

Event Type*

5K Run/Walk for Recovery
Recovery House Bonfire Meeting
Recovery House Pancake Breakfast
PAL Volunteer Event
LSH Alumni Event

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Center Resource*

Resource 1
Resource 2

Please briefly describe what you would like to discuss*

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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

Please create your new member 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

How did you hear about us?

Friend/Family
Treatment Provider
Probation officer
Emergency Department

Reason for Referral*

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:

Do you have health insurance?*

No
Yes
Unknown

Where do you live?*

Describe your living situation, if Other:

Please select which recovery path(s) you use.*

Recovery Path, if Other:

COVID-19 Vaccine Status

Fully Vaccinated
Partially Vaccinated
Unvaccinated

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:

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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)

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