Check-InPlease Check-In to an activity!Site*King CountyPierce CountySnohomish CountyRequest ContactPlease provide the following information and we will get back to you shortly.Section BreakWould you like to remain Anonymous?*YesNoName* First Last Have you registered as a Participant of our Center?*YesNoYour Participant Short Code:*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.I am anonymously attending*Recovery GroupOther EventsNon-Participants can not check in for one-on-one sessions.I am attending-*Group ActivityOther EventsPlease fill our New Participant form below!I am attending:*Group ActivityPeer Coaching (1-on-1)Other EventsRecovery Group*Virtual RoundTableIndoor BoulderingOne Day Atta Time Fit RunsBootcamp WorkoutFitness BoxingTraining Type*Training 1Training 2Event Type*Monthly Community EventReach EventCenter Resource*Resource 1Resource 2Did you receive a ride to this activity/event?YesNoName of person who gave you a ride First Last Please briefly describe what you would like to discuss*Request ContactPlease provide the following information and we will get back to you shortly.I am:*A current ParticipantInterested in becoming a ParticipantPlease 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* First Last Please contact me via:*PhoneEmailPhone or EmailPhone # for Contact*Email for Contact* Please briefly describe what you would like to us to contact you about*New ParticipantPlease create your new participant 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 numberAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?*Friend/FamilyTreatment ProviderProbation officerEmergency DepartmentReason for Referral Select All Education Connection to treatment Connection to recovery community Recovery support Probation Overdose Co-occurring Multiple treatment episodes Demographic InformationDate of Birth* Date Format: MM slash DD slash YYYY Race*WhiteHispanic, Latino, or Spanish OriginBlack or African AmericanMiddle Eastern or North AfricanAmerican Indian or Alaska Native –Asian –Native Hawaiian or Other Pacific IslanderMore than one raceOtherEthnicityHispanicNot HispanicOtherGender*MaleFemaleOtherNonbinaryDo you identify as Transgender*NoYesPrefer not to answerHighest Level of EducationLess than HSHS grad/GEDSome collegeTechnical School/2-yr degree4-yr degree (BS/BA)Graduate degree (Masters or doctorate)Don't KnowRefusedNot ApplicableCOVID-19 Vaccine StatusFully VaccinatedPartially VaccinatedUnvaccinatedCOVID-19 Vaccine WillingnessCurrently VaccinatedWait and SeeOnly When RequiredDefinitely NotAre you interested in Recovery Support Community ?YesNoContact PreferencesI am interested in:*Recovery CoachingTelephonic Recovery SupportsBoth Telephonic and In-person Recovery ServicesThe 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 aboveBest Days to Call: Select All Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Best Time to CallMorningAfternoonEveningAnytime