Sign-In/Drop-In/First Time VisitIf 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 ContactPlease provide the following information and we will get back to you shortly.HiddenSection BreakSiteBostonCentral MAMetrowest MANortheast MASoutheast MAWestern MAAre 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, and birth day in the following format: FL0704 where First Last's birthday is July 4th.I am attending:* Recovery Group Recovery Special Event Recovery Coaching (One-On-One) Training I am attending:* Recovery Group Recovery Special Event Training Recovery Group* YP Committee Meeting YP Peer Support Group YP SMART Recovery Di-Vine Intervention Picnic meeting Turning Pages Recovery Road Rise, Shine, Recovey Creative Culture Cross Talk Training Type* YP Training Event Type* Disc Golf Friday BBQ Middle Way Meditation Center Resource* Resource 1 Resource 2 Please briefly describe what you would like to discuss*HiddenRequest ContactPlease 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, and birth day in the following format: FL0704 where First Last's birthday is July 4th.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 MemberPlease create your new member record.Name* First Last PhonePlease 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".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 Other What are you interested in (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 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-* HiddenDo you have health insurance?* No Yes Unknown HiddenWhere do you live?* Housed Unhoused Shelter Recovery Residence Residential Treatment Institution Halfway House Other Refused HiddenDescribe 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?*54321How do you rate your physical health on a scale of 1-5, 1 being not well, 5 being very well?*54321What 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 HiddenCOVID-19 Vaccine Status Fully Vaccinated Partially Vaccinated Unvaccinated HiddenContact PreferencesHiddenI 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) HiddenConsent 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