Sign-InPlease sign-in as member, guest, or first time visitor.Site*A New Way RSCRequest ContactPlease provide the following information and we will get back to you shortly.Section BreakAre you:*Checking-InVolunteering (members only)First Time VisitHave you registered as a Member of our Center?*YesNoWould you like to check in as a guest?*YesNoSelecting NO will enable you to become a member of our center!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.Name First Last PhoneI am anonymously attending*Recovery GroupRecovery Special EventCenter ResourceNon-Participants can not check in for one-on-one sessions.I am attending-*Recovery GroupRecovery Special EventCenter ResourcePlease fill our New Member form below if you are not a member! OR change to check-in anonymously.I am attending:*Recovery GroupRecovery Group*12 Steps for ACOAAl-AnonAll PathwaysArtistic ExpressionBig BookBurn The BoatCheck MateChips & FlicksCommunity MeetingCreative MindsDaily MotivationDouble WinnersFlab-U-LessFlexibility Friday'sJust BreatheLiving SoberLove TalksMixed MediaN.A.Nail GroupOver Coming Negative ThoughtsQuincy's Men's GroupRelapse PreventionSelf CareSMARTSubtle Art Of Not Giving a F**KThe Are Of MindfulnessThe Sun Will RiseToday's Struggle Tomorrow's StrengthVeterans GroupYogaYou're HiredTraining/Workshop*Training 1Training 2Recovery Event/Activity*Event 1Event 2Please briefly describe what you would like to discuss*What Volunteer activity are you performing?*FoodserviceGroup FacilitationPeer SupportSpecial EventFront DeskCommunity ServiceHow many hours are you volunteering today?*Please enter a number from 0 to 24.Request ContactPlease provide the following information and we will get back to you shortly.I am:*A current MemberInterested in becoming a MemberPlease 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:*PhoneEmailPhone or EmailPhone # for Contact*Email for Contact* Please briefly describe what you would like to us to contact you about*New Peer FormPlease 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 numberAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?*A FriendA Member of A New Way Recovery Support CenterFacebookRecovery Coach/NavigatorThe Safe CoalitionRiverside Community CareThe Hometown WeeklySaw a flier about an event/activityReferred 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 inAn Outreach EventA New Way WebsiteAs 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 InformationDate of Birth* Date Format: MM slash DD slash YYYY Race*WhiteHispanic, Latino, or Spanish OriginBlack or African AmericanMiddle Eastern or North AfricanAmerican Indian or Alaska Native –Asian –Native Hawaiian or Other Pacific IslanderMore than one raceOtherOther RaceEthnicityHispanicNot HispanicOtherOther EthnicityGender (select all that apply)* Male Female Transgender Prefer to Self-Describe Gender*MaleFemaleNonbinaryPrefer to Self-DescribeGenderDo you identify as Transgender*NoYesPrefer not to answerIn what language do you prefer to read or discuss health related materials?EnglishSpanishAre you a veteran?YesNoHighest Level of EducationLess than HSHS grad/GEDSome collegeTechnical School/2-yr degree4-yr degree (BS/BA)Graduate degree (Masters or doctorate)Don't KnowRefusedNot ApplicableWhat is your employment status?Working full or part timeUnemployed and looking for workNot employed and not looking for workOn disabilityStudentRetiredDon't KnowPrefer not to answerOtherDo you have health insurance?YesNoCOVID-19 Vaccine StatusFully VaccinatedPartially VaccinatedUnvaccinatedCOVID-19 Vaccine WillingnessCurrently VaccinatedWait and SeeOnly When RequiredDefinitely NotContact PreferencesI am interested in:*Recovery CoachingTelephonic Recovery SupportsBoth Telephonic and In-person Recovery ServicesVolunteeringDo you want to be place on our email subscription list?YesNoAre you interested in becoming a Peer Volunteer?YesNo. . 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 aboveBest Days to Call: Select All Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Best Time to CallMorningAfternoonEveningAnytime