New ParticipantSite*Serenity House of FlintHow did you hear about us?*TreatmentHealthCareCriminal Justice SystemPeerCommunity AgencyFriend/FamilyName* 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender*MaleFemaleTransgenderOtherNonbinaryPrefer not to answerRace*WhiteHispanic, Latin, or Spanish OriginBlack or African AmericanMiddle Eastern or North AfricanAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderAsianMore than one raceOtherAre you receiving government assistance like medicaid, medicare, SNAP, etc?*YesNoAre you a person in recovery?*YesNoHow 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?*YesNoIf your in active use of substances during the Covid-19, has your substance use...*increaseddecreasedstayed the samedoes not apply
