SCRW Kiosk

Member Check-In/Drop-In

Please use Check-In for group and activity attendance or to meet with your peer coach for a scheduled visit. Otherwise, please use drop-in to meet with an available staff person.

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

Please fill our New Member form below if you are not a member! OR change to check-in anonymously.

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.

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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

You may check-in OR use First Time Visit Above.

I am attending:*

General Support
Recovery and Wellness group(s)
Volunteering
Peer University
Training

Training*

Recovery Coach Academy
Problem Gambling and the Recovery Coach
Problem Gambling 101
Peer Support 101
Recovery Messaging Training
Narcan Administration / Safe syringe disposal
WRAP (Wellness Recovery Action Plan)
Peer Support, Spirituality, and Recovery
Verbal De-escalation 101

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: FL10211901 Where First Last's birth date is 10/21/1901.

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".

Phone*

If you don't have a phone number, please enter (000) 000-0000

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 Visit

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

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Gender*

Male
Female
Other
Nonbinary

Gender (select all that apply)*

Male
Female
Nonbinary
Transgender
Prefer to Self-describe

Gender:

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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:

Peer Support Services
Volunteering/Interning
Information on our Problem Gambling Program

Have you read and do you agree to the Safe Space Agreement?*

Yes
No

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I am interested in:*

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

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:

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Mondays
Tuesdays
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Thursdays
Fridays
Saturdays
Sundays

Best Time to Call

Morning
Afternoon
Evening
Anytime