Kiosk New Way Form

Sign-In
Please sign-in as member, guest, or first time visitor.
Site*
Request Contact
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Are you:*
- Checking-In
- Volunteering (members only)
- 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
Selecting NO will enable you to become a member of our center!
Please click here to fill out the new member form.
Phone for Check-in*
Please enter the phone number you use to check in.
Name*
First Last
Phone
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I am anonymously attending*
- Recovery Group
- Recovery Special Event
- Center Resource
Non-Participants can not check in for one-on-one sessions.
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I am attending-*
- Recovery Group
- Recovery Special Event
- Center Resource
Please fill our New Member form below if you are not a member! OR change to check-in anonymously.
I am attending:*
- Recovery Group
- Recovery Activity or Event
- A New Way Center Resources
Recovery Group*
- Al-Anon
- Artistic Expression
- Bible Study
- Bldg. Recovery Capital
- Broken Chains(Men)
- Burn the Boats
- Codependency
- Computer Skills Lab
- Dharma
- Dual Diagnosis
- Friday Big Book
- Gamblers Anonymous
- Go Check Yo Self
- Holistic Healing
- It’s Your Choice
- Ladies Living Free
- Meet your Shadow
- Men’s A.W.O.L
- Music for Wellness
- Music with Intention
- Narcotics Anonymous
- Open Source
- OPRC Wellness
- Peer Development
- Queer Way
- Quincy Men’s (AA)
- S.M.A.R.T.
- Stages of Change
- Subtle Art of Not Giving a F*%K
- The Sun Will Rise
- Tired not Tipsy
- Veterans
- Voices of Hope
- When I got the Music
- Women’s A.A
- Yoga
Training/Workshop*
- Training 1
- Training 2
Recovery Event/Activity*
- Community Meeting
- Volunteer
- Event Planning
- Outreach Committee
A New Way Center Resources*
- Drop by/safe quiet space
- Meet with recovery coach/recoveree
- Work with a sponsee/sponsor
- Meet with staff
Please briefly describe what you would like to discuss*
What Volunteer activity are you performing?*
- Foodservice
- Group Facilitation
- Peer Support
- Special Event
- Front Desk
- Community Service
- Peer Advisory Council
- Telephone Recovery Support
- Administrative Duties
- Other
Volunteer activity, if Other:*
How many hours are you volunteering today?*
Please enter a number from 0 to 24.
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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
Phone for Check-in*
Please enter the phone number you use to check in.
Name*
First Last
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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 Peer Form
Please create your new participant record.
Name*
First Last
Email*

If you don't have an email address, please input "no@email.com".
Phone*
Please enter (000)-000-0000 if you do not have a phone number
Address*
Street Address Address Line 2 City State ZIP Code

If you do not have an address, please enter 000 Main Street.
How did you hear about us?*
- A Friend
- A Member of A New Way Recovery Support Center
- Facebook
- Recovery Coach/Navigator
- The Safe Coalition
- Riverside Community Care
- The Hometown Weekly
- Saw a flier about an event/activity
- Referred to by a service provider
- (can this have a drop down fillable option to write the name of the provider?)
- Walked by and decided to pop in
- An Outreach Event
- A New Way Website
As it pertains to recovery, how would you describe yourself?
- I am a person in recovery
- I want to be in recovery
- I use substances socially
- Co-occurring Recovery
- I have a family member or a friend who is currently struggling with substance use disorder
- I am a Friend/Family Member/Ally
- Recovery Coach/Navigator
Demographic Information
Date of Birth*
MM slash DD slash YYYY
Race*
- Black or African American
- Asian
- Native Hawaiian or other Pacific Islander
- Alaska Native
- White
- Native American
- Other
- Refused
Other Race
Ethnicity
- Hispanic
- Not Hispanic
Other Ethnicity
If you identify with a specific ethnicity not listed above, please enter it here.
Gender (select all that apply)*
- Male
- Female
- Transgender
- Non-binary
- Other
- Refused
Gender
In what language do you prefer to read or discuss health related materials?
- English
- Spanish
Are you a veteran?
- Yes
- No
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Highest Level of Education
- Less than HS
- HS grad/GED
- Some college
- Technical School/2-yr degree
- 4-yr degree (BS/BA)
- Graduate degree (Masters or doctorate)
- Don't Know
- Refused
- Not Applicable
Where do you live?*
- Housed
- Unhoused
- Shelter
- Recovery Residence
- Residential Treatment
- Institution
- Halfway House
- Other
- Refused
Living Situation, if Other:
What is your employment status?
- Working
- Employed, Full Time
- Employed, Part Time
- Unemployed, Looking for work
- Unemployed, Not looking for work
- Disabled
- Volunteer
- Retired
- Other
- Refused
Do you have health insurance?*
- Yes
- No
Recovery Path*
- Abstinence
- 12-Step Recovery
- Support groups
- Natural Recovery
- Peer Recovery support
- Medication-assisted Recovery
- Harm Reduction
- Alternative/Holistic Recovery
- Other
- Unknown
Recovery Path, if Other:
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COVID-19 Vaccine Status
- Fully Vaccinated
- Partially Vaccinated
- Unvaccinated
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COVID-19 Vaccine Willingness
- Currently Vaccinated
- Wait and See
- Only When Required
- Definitely Not
Contact Preferences
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I am interested in:*
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
- Volunteering
Do you want to be place on our email subscription list?
- Yes
- No
Are you interested in becoming a Peer Volunteer?
- Yes
- No
Please select which days you are available for volunteering:
- Select All
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
. .
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
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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Request Contact

New Peer Form

Demographic Information

Contact Preferences