• AHR Sponsor Ticket
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  • ARCO Leadership Summit 2019 Agenda
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  • clr
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  • F&V Contract
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  • First Time Visit
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  • Illinois Stigma
  • Internal Survey
  • Kiosk 2.0 Template Form
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  • Kiosk CP4R Form
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  • Kiosk CRA Form
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  • LRCC
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  • Uncategorized
Faces & Voices of Recovery Data Hub

Step 1 of 3

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  • 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.
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    Section Break

  • 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.
  • Please enter (000) 000-0000 if you do not have or do not with to give a phone number.
  • Please enter no@email.com if you do not have or do not with to give a phone number.
  • Please enter a number from 0 to 24.
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    Request Contact

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

  • New Member Interest Form

    Please complete this form if you are interested in becoming a member.
  • If you don't have an email address, please input "no@email.com".
  • Please enter (000)-000-0000 if you do not have a phone number
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  • Demographic Information

  • MM slash DD slash YYYY
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  • Contact Preferences

  • 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.
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  • New Volunteer

    Please create your new volunteer record.
  • If you don't have an email address, please input "no@email.com".
  • Please enter (000) 000-0000 if you do not have a phone number.

  • Demographic Information

  • MM slash DD slash YYYY

  • 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 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.
  • 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:

  • Outcome Rating Scale (ORS)

    Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left represent low levels and marks to the right indicate high levels.

  • Craving Rating Scale (CRS)