Kiosk NCHA Form

Check-In/Leave a Message

If you are attending a recovery group, event, center resource, or training, select Check-In. If you are an existing member and would like to leave a message for staff, select Leave a Message.

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Site*

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Section Break

Are you:*

Checking-In
Leaving a Message (Existing Member)

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.

Would you like to check in as a guest?*

Yes
No

Guest Name*

You may enter your first name, a nickname or Anonymous if you do not want to give your full name.

Guest Phone

If you do not have or do not with to leave a phone number, please enter 000-000-0000.

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.

I am attending:*

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

I am attending:*

Recovery Group
Recovery Special Event
Center Resource
Training

Recovery Group*

Group 1
Group 2
Group 3

Event Type*

Event 1
Event 2

Center Resource*

Resource 1
Resource 2

Training Type*

Training 1
Training 2

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

Please create your new member record.

I am completing this form for:

Myself
A patient, client, member, or participant of my organization
A friend or family member

Name of Referring Party

First Last

Organization of Referring Party

Role of Referring Party

Relationship to Individual Being Referred

Phone # of Referring Party

Email of Referring Party

Does your friend or family member know you have placed a referral?

Yes
No

Do you need to upload any of the following documents?

Referring Partner ROI
NCHA Care Coordination ROI
1 Additional Document
2 Additional Documents

Referring Partner ROI

Max. file size: 768 MB.

NCHA Care Coordination ROI

Max. file size: 768 MB.

Additional Document 1

Max. file size: 768 MB.

Additional Document 2

Max. file size: 768 MB.

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*

If you don't have an address, please input where you receive mail or where you stay most often in the Street Address line.

Street Address Address Line 2 City State ZIP Code

How did you hear about us?

Friend/Family
Treatment Provider
Probation officer
Emergency Department
Mental Health or Substance Use Treatment or Recovery Provider
Criminal Justice Provider (Jail or Prison, Courts or Judge, Probation, Parole, Pretrial case manager or officer)

Reason for Referral*

Reason for Referral, if Other:

Additional Referral Reasons

Connection to Treatment with Care Coordination
Connection to support and recovery community
Co-occurring mental health and substance use needs
Health Insurance Enrollment or Navigation
Prescription Assistance
Probation, Parole, Pre-trial, courts
Recent or concern about Overdose and Need for naloxone

Please check any that apply

Demographic Information

Date of Birth*

Race*

Black or African American
Asian
Native Hawaiian/Pacific Islander
Alaska Native
White
Native American
Other
Refused- Decline to Specify

Race, if Other:

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
Refused- Decline to Specify

Gender*

Man
Woman
Transgender
Non-binary
Other
Refused- Decline to Specify

Gender, if Other:

Do you have health insurance?*

No
Yes
Unknown

Type of Insurance

Medicaid ID (if known):

Where do you live?*

Where or how is it easiest to connect with you?

Describe your living situation, if Other:

Please select which recovery path(s) you use or are interested in. (check all that apply)*

Recovery Path, if Other:

Contact Preferences

I am interested in:*

In person support
Phone or Virtual Support
Both in person and phone or virtual support

It's easiest for me to be contacted by:

Address/Location I can be reached in person:

If you cannot get ahold of me (person being referred), I consent to you contacting someone else of my choosing:

Yes, please contact my alternative person via phone.
Yes, please contact my alternative person via email.
Yes, please contact my alternative person via phone or email.
No, please continue just connecting with me.

Name of Alternative Person*

First Last

Phone of Alternative Person*

Email of Alternative Person*

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)

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