Kiosk New Way Form | Faces & Voices of Recovery Data Hub

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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.

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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*

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Please contact me via:*

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Phone # for Contact*

Email for Contact*

Please briefly describe what you would like to us to contact you about*

New Peer Form

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Email*

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Phone*

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Address*

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How did you hear about us?*

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
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Demographic Information

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Gender*

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Gender

Do you identify as Transgender*

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In what language do you prefer to read or discuss health related materials?

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Are you a veteran?

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Highest Level of Education

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COVID-19 Vaccine Status

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COVID-19 Vaccine Willingness

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Contact Preferences

I am interested in:*

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Both Telephonic and In-person Recovery Services
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Do you want to be place on our email subscription list?

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Are you interested in becoming a Peer Volunteer?

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. .

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

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