Check-inIf you are attending a recovery group, event, center resource, or training, select Check-In. Request ContactPlease provide the following information and we will get back to you shortly.HiddenSection BreakHave 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. Name* Guest Email Guest PhoneYour 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.I am attending:* Recovery Group Recovery Special Event Recovery Coaching (One-On-One) Center Resource Training AiR Events I am attending:* Recovery Group Recovery Special Event Center Resource Training AiR Events Recovery Group* All Recovery Family Group SOS Group Event Type* Hope and Healing Hour Strengthening Communities Workshop Center Resource* Harm Reduction Tools Training Type* FAVOR 101 AiR Events* AiR Hike AiR Mini Golf AiR Bowling AiR Fishing AiR Movie Night AiR Game Night AiR Yoga AiR Costume Contest HiddenPlease briefly describe what you would like to discuss*HiddenRequest ContactPlease 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: FL07041970 where First Last's birthday is July 4th, 1970.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 MemberPlease create your new member record.Name* First Last Phone*Please enter (000)-000-0000 if you do not have a phone numberEmail* If you don't have an email address, please input "no@email.com".Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us? Friend/Family Treatment Provider Probation officer Emergency Department Reason for Referral* Select All Housing Employment Education Connection to treatment Connection to recovery community Recovery support Probation Overdose Co-occurring Other Reason for Referral, if Other:* Demographic InformationDate of Birth* MM slash DD slash YYYY Race* Black or African American Asian Native Hawaiian/Pacific Islander Alaska Native White Native American Prefer to Self-Describe Refused Race, if Other: Ethnicity Hispanic or Latino Not Hispanic or Latino Refused Gender* Male Female Transgender Non-binary Prefer to Self-Describe Refused Gender, if Other: Do you have health insurance?* No Yes Unknown Where do you live?* Housed Unhoused Shelter Recovery Residence Residential Treatment Institution Halfway House Other Refused Describe your living situation, if Other: Please select which recovery path(s) you use.* 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: COVID-19 Vaccine Status Fully Vaccinated Partially Vaccinated Unvaccinated Contact PreferencesI 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) Consent FormThe 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