Org Kiosk New Member | Faces & Voices of Recovery Data Hub

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New Member
Site*
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*
Date Format: MM slash DD slash YYYY
Race*
- White
- Black or African American
- Middle Eastern or North African
- American Indian or Alaska Native
- Native Hawaiian or Pacific Islander
- Asian
- More than one race
- Other
Ethnicity
- Hispanic
- Not Hispanic
- Other
Gender*
- Male
- Female
- Transgender
- Other
- Nonbinary
- Prefer not to answer
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

Contact Preferences
I am interested in:*
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
Phone*
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