Your Profile

Add your profile here to make future event registration easier.

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Name*

First Last

Email*

Phone*

May we have your permission to text you?*

Yes

Password*

Enter Password Confirm Password

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County of Residence*

Date of Birth*

MM slash DD slash YYYY

Emergency Contact*

First Last

Emergency Contact Phone*

Do you have any medical conditions we need to be aware of?*

Yes

Medical Conditions*

I participate in the following program(s):*

Person in Recovery

Friend/Family Member of Person in Recovery

Treatment Court - Bucks County

LETI Program - Monroe County

Person living in Sober Living Home

CRS Service

Sync Recovery Volunteer

Please check all that apply.

This question gathers sensitive information strictly for data collection to better understand our community and support funding that keeps our programs accessible. All responses are fully de-identified before reporting to protect your privacy. Please tell us which condition(s) apply:*

Substance Use Disorder

Alcohol Use Disorder

Opiod Use Disorder

Mental Health Conditions

Co-Occuring Conditions

Other

I prefer not to answer

Not applicable

Please check all that apply.

Who needs to know?

Please check this box if you agree.

I understand Synchronicity Recovery Foundation, Ltd believes that participant information should be respected and protected. I understand that SRF representatives will share my attendance record with my Case Manager, Probation Officer, and/or CRS with whom I am working.

How did you hear about Sync Recovery?*

*Who can we thank for introducing you to Sync Recovery?

PO Box 294 Riegelsville, PA 18077
(610) 651-0707
info@syncrecovery.org

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