Kiosk MyPIR Form | Faces & Voices of Recovery Data Hub

Sign-In/Drop-In/First Time Visit
If you are attending a recovery group, event, center resource, or training, select Check-In. If you are want additional information, please select Drop-In.
Request Contact
Please provide the following information and we will get back to you shortly.
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Are you:*
- Checking-In
- Dropping-In (Existing Member)
- First Time Visit
Have you registered as a Member of our Center?*
- Yes
- No
Would you like to check in as a guest?*
- Yes
- No
Please click here to fill out the new member form.
First Name*
Initial of Last Name*
Guest Email*

If you don't have an email address, please input "no@email.com".
Your Participant Short Code:*

Your participant short code is your first initial, last initial, birth month, day and year in the following format: FL01021901 Where First Last's birth date is 10/21/1901.
I am attending:*
- Recovery Group
Recovery Group*
- Monday Night YP Committee Meeting
- Tuesday Night YP Peer Support
- Wednesday Night YP training
- Wednesday Night YP Womens Peer Support
- Friday FYP peer support
- Friday Game/Movie Night
Training Type*
- Training 1
- Training 2
Event Type*
- Event 1
- Event 2
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".
Location*
- Boston
- Central MA
- Metrowest MA
- Northeast MA
- Southeast MA
- Western MA
How did you hear about MyPIR?
- Friend/Family
- Treatment Provider
- Probation officer
- Emergency Department
What are you interested in?*
- Select All
- Housing
- Employment
- Education
- Connection to treatment
- Connection to recovery community
- Recovery support
- Probation
- Overdose
- Co-occurring
- Multiple treatment episodes
- Other
What are you interested in (if Other)?*
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
- Prefer to Self-Describe
- Refused
Race-*
Ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
- Refused
Gender*
- Male
- Female
- Transgender
- Non-binary
- Prefer to Self-Describe
- Refused
Gender-*
Orientation/Identity*
- Straight/Heterosexual
- Gay/Lesbian
- Bisexual
- Queer
- Prefer to Self-Describe
- Refused
Orientation-*
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Do you have health insurance?*
- No
- Yes
- Unknown
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Where do you live?*
- Housed
- Unhoused
- Shelter
- Recovery Residence
- Residential Treatment
- Institution
- Halfway House
- Other
- Refused
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Describe your living situation, if Other:
How do you rate your mental health on a scale of 1-5, 1 being not well, 5 being very well?*
How do you rate your physical health on a scale of 1-5, 1 being not well, 5 being very well?*
What is your substance of choice?
- Alcohol
- Amphetamines
- Benzodiazepines
- Caffeine
- Cocaine/Crack
- Fentanyl
- Hallucinogens/Psychedelics
- Inhalants
- Kratom
- Marijuana/Hashish/Synthetic Cannabis
- Opiates
- Other Substances
- Tobacco/Nicotine
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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:
- 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

Sign-In/Drop-In/First Time Visit

Request Contact

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Request Contact

New Member

Demographic Information

Contact Preferences

Consent Form