Your Profile

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Name*

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Email*

Phone*

May we have your permission to text you?*

Yes

Password*

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Address*

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

County of Residence*

Date of Birth*

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Emergency Contact*

First Last

Emergency Contact Phone*

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

Opioid Use Disorder

Mental Health Conditions

Co-Occuring Conditions

Other

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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?

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I do not want my image, likeness, or photographs of me to be used in any Sync Recovery communications, including newsletters, social media, promotional materials, or website content.

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

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