Kiosk Recovery Beyond Form

Event Check In

By checking into this event, you acknowledge and agree to the terms outlined in our participation waiver, which can be found on the Forms page at recoverybp.org. This waiver details the expectations, responsibilities, and potential risks involved in participating, as well as your agreement to hold the organization and its affiliates harmless. Please review and sign the one-time waiver before completing your first RB event, as your participation indicates your acceptance of these terms. Thank you!

Request Contact

Please provide the following information and we will get back to you shortly.

This field is hidden when viewing the form

Section Break

What's your connection to Recovery Beyond today?*

Member
Guest
Volunteer

Your Member 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.

Guest Name*

First Last

Guest Phone*

Please enter (000) 000-0000 if you do not have or do not with to give a phone number.

Guest Email*

Please enter no@email.com if you do not have or do not with to give a phone number.

Guest City*

City

How long are you planning on volunteering today?*

Please enter a number from 0 to 24.

Type of Volunteer*

Activity Lead
Activity Support
Peer Lead
First Aid

I am attending:*

Virtual Group Event
Onsite Group Event
Recovery Coaching (One-On-One)

I am attending:*

Virtual Group Event
Onsite Group Event

Virtual Group Event*

New Member Orientation
Training & Education
RB Live
Virtual Huddle
Community & Culture Council
Peer Advisory Council

Onsite Group Event*

Did you receive a ride to this activity/event?

Yes
No

Name of person who gave you a ride

First Last

Please briefly describe what you would like to discuss*

This field is hidden when viewing the form

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

Please Enter Your Member Short Code:*

Your member 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:*

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 Member

Please create your new member 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

How did you hear about us?*

Friend/Family
Treatment Provider
Probation officer
Emergency Department

Reason for Referral*

Reason for Referral, if Other:

Demographic Information

Date of Birth*

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?*

Describe your living situation, if Other:

Please select which recovery path(s) you use:*

Recovery Path, if Other:

Highest Level of Education

Are you a Military Veteran?

Yes
No

Contact Preferences

I am interested in:*

Group Recovery Activities
1-on-1 Recovery Coaching Support

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.

This field is hidden when viewing the form

Consent

I agree to the above

This field is hidden when viewing the form

Best Days to Call:

Select All
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

This field is hidden when viewing the form

Best Time to Call

Morning
Afternoon
Evening
Anytime

New Volunteer

Please create your new volunteer 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

Demographic Information

Date of Birth*

Race*

Black or African American
Asian
Native Hawaiian/Pacific Islander
Alaska Native
White
Native American
Other
Refused

Race, if Other:

Gender*

Male
Female
Transgender
Non-binary
Other
Refused

Gender, if Other:

Are you a Military Veteran?*

Yes
No

Monthly Quick Checks

Please complete the following Monthly Assessments. ALL fields are required. You will be completing the Brief Assessment of Recovery Capital, Outcome Rating Scale, and Craving Rating Scale.

Your Member Short Code:*

Your member 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.

Email

If you would like an email notification that you have submitted your assessment, please enter your email here.

Brief Assessment of Recovery Capital(BARC-10)

Please indicate your level of agreement with the following statements:

There are more important things to me in life than using substances*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

In general I am happy with my life*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

I have enough energy to complete the tasks I set myself*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

I am proud of the community I live in and feel part of it*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

I get lots of support from friends*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

I regard my life as challenging and fulfilling without the need for using drugs or alcohol*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

My living space has helped to drive my recovery journey*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

I take full responsibility for my actions*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

I am happy dealing with a range of professional people*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

I am making good progress on my recovery journey*

Strongly Disagree
Disagree
Somewhat Disagree
Somewhat Agree
Agree
Strongly Agree

Step 1 of 3

Event Check In

Request Contact

Section Break

Request Contact

New Member

Demographic Information

Contact Preferences

New Volunteer

Demographic Information

Monthly Quick Checks

Brief Assessment of Recovery Capital(BARC-10)

Outcome Rating Scale (ORS)

Craving Rating Scale (CRS)