Kiosk Turning Point Form

Sign-In

Please sign-in as member, guest, or first time visitor.

Site*

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Are you:*

Signing-In
Peer Volunteer
First Time Visit

Have you registered as a Member of our Center?*

Yes
No

Would you like to check in as a guest?*

Yes
No

Selecting NO will enable you to become a member of our center!

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.

Name*

Phone

Email

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I am anonymously attending*

Recovery Group
Recovery Special Event
Center Resource

Non-Participants can not check in for one-on-one sessions.

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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 here for:*

Recovery Support Group
Recovery Education
Recovery Activity or Event
Community Meeting/Committee
Other Turning Point Resource

Recovery Support Group*

Recovery Education*

Member Orientation
Facilitator Training
Coffee with a Coach
Suicide Prevention Training

Recovery Activity or Event*

Reiki Healing
Orange Theory Work Out
Book Club
Sound Journey and Reiki
Family Dinner
Easel Does it
Serenity in Yoga Movement
Friday Night Bites

Community Meeting/Committee*

Community Meeting
Outreach Team
Events Committee
Advisory Board
Skill Lab Development

Turning Point Center Resources*

Drop by/safe quiet space
Meet with recovery coach/recoveree
Work with a sponsee/sponsor
Meet with staff

Please briefly describe what you would like to discuss*

What Volunteer activity are you performing?*

Volunteer activity, if Other:*

How many hours are you volunteering today?*

Please enter a number from 0 to 24.

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Request Contact

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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

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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 Participant Form

Please 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 number

Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about us?*

As it pertains to recovery, how would you describe yourself?

I am a person in recovery
I want to be in recovery
I use substances socially
I am a friend, family member and/or ally of recovery
Recovery Coach/Navigator
Other/None of the above

Demographic Information

Date of Birth*

Are you Spanish/Hispanic/Latino*

Yes
No
Other

What is your ethnicity?*

Central American
Cuban
Dominican
Mexican, Mexican American, Chicano
Puerto Rican
Salvadorian
South American
Unknown
Other

What is your ethnicity-?*

Other Ethnicity*

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

Other Race*

Gender (select all that apply)*

Male
Female
Transgender
Prefer to Self-Describe

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Gender*

Male
Female
Nonbinary
Prefer to Self-Describe

Gender*

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Do you identify as Transgender*

No
Yes
Prefer not to answer

In what language do you prefer to read or discuss health related materials?*

English
Spanish

Are you a veteran?

Yes
No

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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

What is your employment status?

Working full or part time
Unemployed and looking for work
Not employed and not looking for work
On disability
Student
Retired
Don't Know
Prefer not to answer
Other

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Do you have health insurance?

Yes
No

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COVID-19 Vaccine Status

Fully Vaccinated
Partially Vaccinated
Unvaccinated

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COVID-19 Vaccine Willingness

Currently Vaccinated
Wait and See
Only When Required
Definitely Not

Contact Preferences

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I am interested in:*

Recovery Coaching
Telephonic Recovery Supports
Both Telephonic and In-person Recovery Services
Volunteering

Do you want to be place on our email subscription list?

Yes
No

Are you interested in becoming a Peer Volunteer?

Yes
No

. .

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

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