Kiosk Template 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)
- First Time Visit
Would you like to remain Anonymous?*
- Yes
- No
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
Please fill our New Member form below if you are not a member! OR change to check-in anonymously.
I am attending:*
- Recovery Group
- Recovery Special Event
- Recovery Coaching (One-On-One)
- Center Resource
- Training
Recovery Group*
- Group 1
- Group 2
- Group 3
Training Type*
- Training 1
- Training 2
Event Type*
- Event 1
- Event 2
Center Resource*
- Resource 1
- Resource 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.
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, 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".
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
- Select All
- Housing
- Employment
- Education
- Connection to treatment
- Connection to recovery community
- Recovery support
- Probation
- Overdose
- Co-occurring
- Multiple treatment episodes
Demographic Information
Date of Birth*
MM slash DD slash YYYY
Race*
- White
- Hispanic, Latino, or Spanish Origin
- Black or African American
- Middle Eastern or North African
- American Indian or Alaska Native –
- Asian –Native Hawaiian or Other Pacific Islander
- More than one race
- Other
Ethnicity
- Hispanic
- Not Hispanic
- Other
Gender*
- Male
- Female
- Other
- Nonbinary
Do you identify as Transgender*
- No
- Yes
- Prefer not to answer
Highest Level of Education
- Less than HS
- HS grad/GED
- Some college
- Technical School/2-yr degree
- 4-yr degree (BS/BA)
- Graduate degree (Masters or doctorate)
- Don't Know
- Refused
- Not Applicable
COVID-19 Vaccine Status
- Fully Vaccinated
- Partially Vaccinated
- Unvaccinated
COVID-19 Vaccine Willingness
- Currently Vaccinated
- Wait and See
- Only When Required
- Definitely Not
Contact Preferences
I am interested in:*
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
Phone*
Please enter (000)-000-0000 if you do not have a phone number
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
Best Days to Call:
- Select All
- Mondays
- Tuesdays
- Wednesdays
- Thursdays
- Fridays
- Saturdays
- Sundays
Best Time to Call
- Morning
- Afternoon
- Evening
- Anytime