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.

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Site*

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Section Break

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Are you:*

Checking-In
Leaving a Message (Existing Member)

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Have you registered as a Member of our Center?*

Yes
No

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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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Would you like to check in as a guest?*

Yes
No

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Guest Name*

You may enter your first name, a nickname or Anonymous if you do not want to give your full name.

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Guest Phone

If you do not have or do not with to leave a phone number, please enter 000-000-0000.

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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.

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I am attending:*

Recovery Group
Recovery Special Event
Recovery Coaching (One-On-One)
Center Resource
Training

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I am attending:*

Recovery Group
Recovery Special Event
Center Resource
Training

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Recovery Group*

Recovery Support Services Group #1
Recovery Support Services Group #2

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Event Type*

All Recovery Meetings

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Center Resource*

Recovery Coaching
Resources/Referrals
Intake Appointment

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Training Type*

Workforce Development Class
Overdose Prevention and Naloxone Training
Recovery Coach Training

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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.

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I am:*

A current Member
Interested in becoming a Member

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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.

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Name*

First Last

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Please contact me via:*

Phone
Email
Phone or Email

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Phone # for Contact*

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Email for Contact*

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Please briefly describe what you would like to us to contact you about*

New ARCHES Initial Contact Form

Program Selection*

Referral Source*

Social Worker

Peer

Name*

First Middle 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".

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Address*

Street Address Address Line 2 City State ZIP Code

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How did you hear about us?

Friend/Family
Treatment Provider
Probation officer
Emergency Department

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Reason for Referral*

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Reason for Referral, if Other:

Demographic Information

Gender*

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Gender, if Other:

Pronoun*

Race*

White
Black
Native Hawaiian/Pacific Islander
Asian
Native American
Other
Refused

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Race, if Other:

Ethnicity*

Hispanic or Latino
Not Hispanic or Latino
Refused

Health Insurance*

Where do you live?*

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Describe your living situation, if Other:

Treatment*

Employed

Yes
No
Refused

Veteran

Family Support

CRAFT Provided

Meeting Notes

Recovery

Stage

Outcome

Harm Reduction

Narcan
Fentanyl Test
Naloxone
Xylazine Test
None

MAT Type

Drugs of Choice

Other Drugs of Choice*

Quality of Life Scale

1 is Poor and 8 is Great

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Please select which recovery path(s) you use.*

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Recovery Path, if Other:

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COVID-19 Vaccine Status

Fully Vaccinated
Partially Vaccinated
Unvaccinated

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Contact Preferences

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I am interested in:*

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

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Best Days to Call:

Select All
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

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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