Step 1 of 2 50% New MemberSite*Site1Site2Name* First Last Email* If you don't have an email address, please input "no@email.com".Address* 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 Housing Employment 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*WhiteBlack or African AmericanMiddle Eastern or North AfricanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianMore than one raceOtherEthnicityHispanicNot HispanicOtherGender*MaleFemaleTransgenderOtherNonbinaryPrefer not to answerDo 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 Applicable Contact PreferencesI am interested in:*Recovery CoachingTelephonic Recovery SupportsBoth Telephonic and In-person Recovery ServicesPhone*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 aboveBest Days to Call: Select All Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Best Time to CallMorningAfternoonEveningAnytime
