USARA ARCHES

Check-In/Leave a Message
If you are attending a recovery group, event, center resource, or training, select Check-In. If you are an existing member and would like to leave a message for staff, select Leave a Message.
Site*
Section Break
Are you:*
- Checking-In
- Leaving a Message (Existing Member)
Have you registered as a Member of our Center?*
- Yes
- No
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.
Would you like to check in as a guest?*
- Yes
- No
Guest Name*
You may enter your first name, a nickname or Anonymous if you do not want to give your full name.
Guest Phone
If you do not have or do not with to leave a phone number, please enter 000-000-0000.
Guest Email

If you do not have or do not with to leave an email address, please enter no@email.com.
Please click here to fill out the new member form.
I am attending:*
- Recovery Group
- Recovery Special Event
- Recovery Coaching (One-On-One)
- Center Resource
- Training
I am attending:*
- Recovery Group
- Recovery Special Event
- Center Resource
- Training
Recovery Group*
- Recovery Support Services Group #1
- Recovery Support Services Group #2
Event Type*
- All Recovery Meetings
Center Resource*
- Recovery Coaching
- Resources/Referrals
- Intake Appointment
Training Type*
- Workforce Development Class
- Overdose Prevention and Naloxone Training
- Recovery Coach Training
Please briefly describe what you would like to discuss*
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: FL01311990 Where First Last's birth date is 01/31/1990.
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 ARCHES Initial Contact Form
If you are an existing participant, please enter your 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.
Program Selection*
Referral Source*
Other Referral Source*
Social Worker
Assigned Peer
Peer
Name*
First Last
Date of Birth*
Phone*
Please enter (000)-000-0000 if you do not have a phone number
Family Phone
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
- Other
Reason for Referral, if Other:
Demographic Information
Gender*
Gender, if Other:
Pronoun*
Race*
- White
- Black
- Native Hawaiian/Pacific Islander
- Asian
- Native American
- Other
- Refused
Race, if Other:
Ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
- Refused
Health Insurance*
- None
- Private- Employer
- Medicaid
- Medicare
- Medicaid and Medicare
- Other
Where do you live?*
- Own Home
- Family Home
- Unhoused
- Shelter
- Treatment
- Refused
Describe your living situation, if Other:
Treatment*
Employed
- Yes
- No
- Refused
Veteran
Family Support
Family Support
CRAFT Provided
Meeting Notes
Recovery
Stage
Outcome
Harm Reduction
- Narcan
- Fentanyl Test
- Naloxone
- Xylazine Test
- None
MAT Type
Drugs of Choice
- Alcohol
- Benzodiazepines
- Barbiturates
- Sedatives(Ambien Lunesta)
- Barbiturates(Phenobarbital)
- Meth
- Crack Cocaine
- Cocaine
- Marijuana
- Synthetic (Spice)
- Heroin
- Prescription Pills(Oxycodone,Morphine)
- Fentanyl
- Methadone
- Buprenorphine(Suboxone)
- Nitrous Oxide(Whippets)
- Solvents(Paint Thinner,Glue)
- Aerosols(Spray Paints)
- MDMA(Ecstasy, Molly)
- GHB
- Rohypnol
- LSD
- Psilocybin(Mushrooms)
- PCP(Phencyclidine)
- Ketamine
- Synthetic Cathinones(Bath Salts)
- Steroids
- Kratom
- Other
Other Drugs of Choice*
Quality of Life Scale
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
1 is Poor and 8 is Great
Please select which recovery path(s) you use.*
- Abstinence
- 12-Step Recovery
- Support groups
- Natural Recovery
- Peer Recovery support
- Medication-assisted Recovery
- Harm Reduction
- Alternative/Holistic Recovery
- Other
- Unknown
Recovery Path, if Other:
COVID-19 Vaccine Status
- Fully Vaccinated
- Partially Vaccinated
- Unvaccinated
Contact Preferences
I am interested in:*
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
Best Days to Call:
- Select All
- Mondays
- Tuesdays
- Wednesdays
- Thursdays
- Fridays
- Saturdays
- Sundays
Best Times to Call:
- Select All
- Morning (Before 9)
- Late Morning (9 to 12)
- Afternoon (12 to 3)
- Late Afternoon (3 to 6)
- Evening (6 to 9)
- Late Night (After 9)
Authorization for Contact
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
Verbal Authorization Given
Verbal Authorization Witnessed By:
Verbal Authorization Witnessed By

Check-In/Leave a Message

Section Break

Request Contact

New ARCHES Initial Contact Form

Demographic Information

Family Support

Recovery

Contact Preferences

Authorization for Contact