SHOF New Member | Faces & Voices of Recovery Data Hub

New Participant
Site*
How did you hear about us?*
- Treatment
- HealthCare
- Criminal Justice System
- Peer
- Community Agency
- Friend/Family
Name*
First Last
Phone*
If you don't have a current phone number, please input "No phone".
Email*

If you don't have an email address, please input "no@email.com".
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Gender*
Race*
Are you receiving government assistance like medicaid, medicare, SNAP, etc?*
- Yes
- No
Are you a person in recovery?*
- Yes
- No
How long have you been in recovery?*
Date Format: MM slash DD slash YYYY
As a result of the Covid-19 have you returned back to active use?*
- Yes
- No
If your in active use of substances during the Covid-19, has your substance use...*
- increased
- decreased
- stayed the same
- does not apply