OHH Kiosk RH

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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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*

Please Use NA if Street Address is unavailable

Street Address Address Line 2 City State ZIP Code

Lives In

How did you hear about us?*

Operation Helping Hand
Friend/Family
Treatment Provider
Probation officer
Emergency Department

Reason for Referral

Consent

I agree to participate in Operation Helping Hand

My de-identified information can be shared with Operation Helping Hand for tracking outcomes of services.

Demographic Information

Date of Birth*

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

Veteran Discharge Status*

Veteran
Not A Veteran

Employment Status

Age of first use*

Please enter a number from 0 to 100.

First Substance(s) Used

Challenging Substances*

Services Tried*

Do you have a Physical Health Diagnosis*

No
Yes
Unknown

Physical Health Diagnosis Details

Do you have a Behavioral Health Diagnosis*

No
Yes
Unknown

Behavioral Health Diagnosis Details

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

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Best Time to Call

Morning
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Anytime