Kiosk MyPIR Form

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.

This field is hidden when viewing the form

Section Break

Site

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, 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*

Training Type*

YP Training

Event Type*

Disc Golf
Friday Fellowship
Boxfit
Monthly Outing

Center Resource*

Resource 1
Resource 2

Please briefly describe what you would like to discuss*

This field is hidden when viewing the form

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, 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 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*

How did you hear about MyPIR?

Friend/Family
Treatment Provider
Probation officer
Emergency Department

What are you interested in?*

What are you interested in (if Other)?*

Demographic Information

Date of Birth*

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-*

This field is hidden when viewing the form

Do you have health insurance?*

No
Yes
Unknown

This field is hidden when viewing the form

Where do you live?*

This field is hidden when viewing the form

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?*

This field is hidden when viewing the form

COVID-19 Vaccine Status

Fully Vaccinated
Partially Vaccinated
Unvaccinated

This field is hidden when viewing the form

Contact Preferences

This field is hidden when viewing the form

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)

This field is hidden when viewing the form

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