RecoveryLink™ – LRCC - First Time Visit

Self-Serve Kiosk - First Time Visit

First Name *

Last Name *

Email *

Confirm Email *

Reason for visiting: * Reason for visiting:

How did you hear about us? * How did you hear about us?

Are you interested in becoming a member? *

Yes

No

Address *

Address

City

State/Province

Zip/Postal

Phone *

Date of Birth *

Gender Identity * Gender Identity

Race/Ethnicity * Race/Ethnicity

Please select all that apply.

Current Insurance Coverage:

Current employment:

Current housing situation: Current housing situation:

Current transportation status:

How do you identify yourself? How do you identify yourself?

Are you interested in becoming a volunteer? *

Yes

No

Phone *

Days you are available to volunteer: *

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What are you most interesting in doing as a volunteer? What are your skills and interests?

Would you be willing to provide limited demographic information about yourself to help us improve our services? *

Yes

No

Gender Identity Gender Identity