Kiosk Reality Check Form - Faces & Voices of Recovery Data Hub

Check-In/Drop-In/First Time Visit
If you are attending a recovery group, event, center resource, or training, select Check-In. If you are here to see your Recovery Coach, select Drop-In.
Site*
Request Contact
Please provide the following information and we will get back to you shortly.
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Section Break
Are you:*
- Checking-In
- Dropping-In (Existing Member)
Would you like to remain Anonymous?*
- Yes
- No
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Name
First Last
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.
I am anonymously attending*
- Recovery Group
- Recovery Special Event
- Center Resource
Non-Participants can not check in for one-on-one sessions.
I am attending:*
- Recovery Group
- Recovery Special Event
- Center Resource
- Training
Please click here fill to sign up for services.
Recovery Group*
- Alcoholics Anonymous
- Families, Addiction & Loss
- Mental Health & Addiction
- Recovery Creative Arts
Event Type*
- Placeholder Event 1
- Placeholder Event 1
Center Resource*
- Walk-In
- Appointment
- Meeting
- Volunteer
Training*
- Placeholder Training 1
- Placeholder Training 2
Please briefly describe what you would like to discuss*
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Request Contact
Please provide the following information and we will get back to you shortly.
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*
Sign Up
Please complete this form to sign up for services.
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*
Street Address Address Line 2 City State ZIP Code
How did you hear about us?
- Friend/Family
- Treatment Provider
- Probation officer
- Emergency Department
I need help with:*
- Select All
- Housing
- Employment
- Education
- Connection to treatment
- Connection to recovery community
- Recovery support
- Probation
- Overdose
- Co-occurring
- Multiple treatment episodes
- Other
I need help with, if Other:*
Demographic Information
Date of Birth*
MM slash DD slash YYYY
Race*
- Black or African American
- Asian
- Native Hawaiian/Pacific Islander
- Alaska Native
- White
- Native American
- Other
- Refused
Race, if Other:
Ethnicity
- Hispanic or Latino
- Not Hispanic or Latino
- Refused
Gender*
- Male
- Female
- Transgender
- Non-binary
- Other
- 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 Preferences
I 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 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