{"id":988,"date":"2024-11-24T03:37:12","date_gmt":"2024-11-24T03:37:12","guid":{"rendered":"https:\/\/empowercommunityinitiative.org\/?page_id=988"},"modified":"2024-11-24T03:39:15","modified_gmt":"2024-11-24T03:39:15","slug":"enrollment","status":"publish","type":"page","link":"https:\/\/empowercommunityinitiative.org\/?page_id=988","title":{"rendered":"Enrollment"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"988\" class=\"elementor elementor-988\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0445a22 e-flex e-con-boxed e-con e-parent\" data-id=\"0445a22\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-3c777a9 e-con-full e-flex e-con e-child\" data-id=\"3c777a9\" data-element_type=\"container\">\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-cf82afe e-con-full e-flex e-con e-child\" data-id=\"cf82afe\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ad36b78 elementor-widget elementor-widget-heading\" data-id=\"ad36b78\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Contact Information<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fd51e14 elementor-widget elementor-widget-text-editor\" data-id=\"fd51e14\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Your contact and recovery information helps us provide better recovery support.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-abda57c elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"abda57c\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-84e89d0 elementor-widget__width-inherit elementor-widget elementor-widget-shortcode\" data-id=\"84e89d0\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f967-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"967\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F988#wpcf7-f967-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"967\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f967-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:967,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-928&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;IAuthorized-YorN&quot;,&quot;operator&quot;:&quot;not empty&quot;,&quot;if_value&quot;:&quot;1&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_uacf7_hidden_conditional_fields\" value=\"\" \/>\n<\/div>\n<div class=\"uacf7-form-967 uacf7_auto_cart_967\"><div style=\"font-weight: 900\">\n<div style=\"padding: 20px\">\n   <div class=\"uacf7-row\"><div class=\"\"> \n      <div style=\"width: 160%\">\n         <span class=\"wpcf7-form-control-wrap\" data-name=\"FirstName\"><input size=\"40\" maxlength=\"17\" minlength=\"3\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required firstname\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"FirstName\" \/><\/span> \n       <\/div>\n   <\/div><div class=\"uacf7-col-3\"> \n       <div style=\"width: 160%\">\n         <span class=\"wpcf7-form-control-wrap\" data-name=\"LastName\"><input size=\"40\" maxlength=\"17\" minlength=\"3\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required lastname\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"LastName\" \/><\/span> \n       <\/div>\n   <\/div><div class=\"\"> \n       <div style=\"width: 160%; border: none\">\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"emailaddress\"><input size=\"40\" maxlength=\"400\" minlength=\"8\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"emailaddress\" \/><\/span>\n       <\/div>\n<\/div>\n\n<div style=\"padding-right: 20px\">\n<div style=\"margin: 15px\">\n<label style=\"font-weight: 900\"> Address : <\/label>\n<\/div>\n<div style=\"margin-right: 3px\">\n  <span class=\"wpcf7-form-control-wrap\" data-name=\"AddressLine1\"><input size=\"40\" maxlength=\"400\" minlength=\"6\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required AddressLine1\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address Line 1\" value=\"\" type=\"text\" name=\"AddressLine1\" \/><\/span>\n<\/div>\n<div>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"AddressLine2\"><input size=\"40\" maxlength=\"400\" minlength=\"6\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required AddressLine1\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address Line 2\" value=\"\" type=\"text\" name=\"AddressLine2\" \/><\/span>\n<\/div>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"City\"><input size=\"40\" maxlength=\"20\" minlength=\"3\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required City\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"City\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"State\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required State\" aria-required=\"true\" aria-invalid=\"false\" name=\"State\"><option value=\"\">Please select your answer<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"Iowa\">Iowa<\/option><option value=\"North Dakota\">North Dakota<\/option><option value=\"South Dakota\">South Dakota<\/option><option value=\"Illinois\">Illinois<\/option><\/select><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ZipCode\"><input size=\"40\" maxlength=\"400\" minlength=\"5\" class=\"wpcf7-form-control wpcf7-text ZipCode\" aria-invalid=\"false\" placeholder=\"Zip Code\" value=\"\" type=\"text\" name=\"ZipCode\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Phone\"><input size=\"40\" maxlength=\"15\" minlength=\"7\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel Phone\" autocomplete=\"tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone Number\" value=\"\" type=\"tel\" name=\"Phone\" \/><\/span>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"SecondryPhone\"><input size=\"40\" maxlength=\"400\" minlength=\"7\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel SecondryPhone\" aria-invalid=\"false\" placeholder=\"Secondry Phone Number\" value=\"\" type=\"tel\" name=\"SecondryPhone\" \/><\/span>\n<div style=\"margin-top: 15px\">\n<label style=\"font-weight: bold\">Call Preferences:<\/label>\n<\/div>\n<label>Can we (ECI) leave you a voice message?<\/label>\n<div style=\"margin-left: 15px\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Call_Pref\"><span class=\"wpcf7-form-control wpcf7-radio Call_Pref\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"Call_Pref\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"Call_Pref\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<div><\/br><\/div>\n<label>Best time of day we can contact you (select all that apply)<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Best_To_Contact\"><span class=\"wpcf7-form-control wpcf7-checkbox Best_To_Contact\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"Best_To_Contact[]\" value=\"Morning:(9am-1pm)\" \/><span class=\"wpcf7-list-item-label\">Morning:(9am-1pm)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"Best_To_Contact[]\" value=\"Afternoon:(1pm-4pm)\" \/><span class=\"wpcf7-list-item-label\">Afternoon:(1pm-4pm)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"Best_To_Contact[]\" value=\"Evening:(4pm-6pm)\" \/><span class=\"wpcf7-list-item-label\">Evening:(4pm-6pm)<\/span><\/label><\/span><\/span><\/span>\n<div><\/br><\/div>\n<label>Best day of week to be contacted  (select all that apply)<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"WeekDays\"><span class=\"wpcf7-form-control wpcf7-checkbox WeekDays\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"WeekDays[]\" value=\"Monday\" \/><span class=\"wpcf7-list-item-label\">Monday<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"WeekDays[]\" value=\"Tuesday\" \/><span class=\"wpcf7-list-item-label\">Tuesday<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"WeekDays[]\" value=\"Wednesday\" \/><span class=\"wpcf7-list-item-label\">Wednesday<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"WeekDays[]\" value=\"Thursday\" \/><span class=\"wpcf7-list-item-label\">Thursday<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"WeekDays[]\" value=\"Friday\" \/><span class=\"wpcf7-list-item-label\">Friday<\/span><\/label><\/span><\/span><\/span>\n<div><\/br><\/div>\n<div>\n<label>How did you hear us (select all that apply)<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"how-didU-hearUs\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"how-didU-hearUs\"><option value=\"\">Please Select your answer<\/option><option value=\"Friend\">Friend<\/option><option value=\"Family\">Family<\/option><option value=\"Website\">Website<\/option><option value=\"Flyer\">Flyer<\/option><option value=\"Our staff\">Our staff<\/option><option value=\"Walk-in\">Walk-in<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n<label>If other, please specify who referred you<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"whoReferred-U\"><input size=\"40\" maxlength=\"15\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"Enter name of the person?\" type=\"text\" name=\"whoReferred-U\" \/><\/span>\n<div  style=\"padding-top: 10px\">\n<label>Date Of Birth<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DOB\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" min=\"1999-01-02\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"DOB\" \/><\/span>\n<label style=\"margin-top: 10px\">Gender<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"Gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"Gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n<label style=\"margin-top: 10px\">How do you identify your racial group?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"racialGrp\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"racialGrp\"><option value=\"\">Please select your answer<\/option><option value=\"Black\/African\">Black\/African<\/option><option value=\"Hispanic\/Latino\">Hispanic\/Latino<\/option><option value=\"Asian\">Asian<\/option><option value=\"Caucasian\/White\">Caucasian\/White<\/option><option value=\"Middle Eastern\">Middle Eastern<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 10px\">Do you live on a reservation?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DoU-LiveInResv\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"DoU-LiveInResv\"><option value=\"\">Please select your answer<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 10px\">What is your Recovery date<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"RecoveryDate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"2025-01-03\" type=\"date\" name=\"RecoveryDate\" \/><\/span>\n<label style=\"margin-top: 10px\">Have you been to treatment before?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"TreatmentBefore\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"TreatmentBefore\"><option value=\"\">Please select your answer<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 10px\">Are you currently on probation or parole?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ProbationBefore\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"ProbationBefore\"><option value=\"\">Please select your answer<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 10px\">When was the date of last use?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateLastUse\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"DateLastUse\" \/><\/span>\n<label style=\"margin-top: 10px\">What is your primary addiction or drug of choice?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PrimaryType\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"PrimaryType\" \/><\/span>\n<p style=\"margin-top: 20px\"> What types of recovery support are you currently getting? (please select all that apply.)<\/p>\n<div><\/br><\/div>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"RecoveryTypes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Peer support\" \/><span class=\"wpcf7-list-item-label\">Peer support<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"12-Step groups\" \/><span class=\"wpcf7-list-item-label\">12-Step groups<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Mental health counseling\" \/><span class=\"wpcf7-list-item-label\">Mental health counseling<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Assistance with physical health\" \/><span class=\"wpcf7-list-item-label\">Assistance with physical health<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Spiritual or religious support\" \/><span class=\"wpcf7-list-item-label\">Spiritual or religious support<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Sober housing\" \/><span class=\"wpcf7-list-item-label\">Sober housing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Relationship or family counseling\" \/><span class=\"wpcf7-list-item-label\">Relationship or family counseling<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Focusing on work\" \/><span class=\"wpcf7-list-item-label\">Focusing on work<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Exercise or nutrition\" \/><span class=\"wpcf7-list-item-label\">Exercise or nutrition<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Focusing on hoppy\" \/><span class=\"wpcf7-list-item-label\">Focusing on hoppy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"RecoveryTypes[]\" value=\"Choose not to answer\" \/><span class=\"wpcf7-list-item-label\">Choose not to answer<\/span><\/label><\/span><\/span><\/span>\n<div><\/br><\/div>\n<label style=\"margin-top: 20px\">Do you currently use nicotine products?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"currentUseProduct\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"currentUseProduct\"><option value=\"\">Please select your answer<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 15px\">Do you currently have a stable place to live?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"currentPlaceToLive\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"currentPlaceToLive\"><option value=\"\">Please select your answer<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 15px\">What is your marital status?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MaritalStatus\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"MaritalStatus\"><option value=\"\">Please select your answer<\/option><option value=\"Single\">Single<\/option><option value=\"Married\">Married<\/option><option value=\"Divorced\">Divorced<\/option><option value=\"Separated\">Separated<\/option><option value=\"Widowed\">Widowed<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 15px\">What is the size of your household?<\/label>\n<label style=\"color: red\">(Attention: Your household includes you, your spouse, and tax dependents.)<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"familySize\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"familySize\"><option value=\"\">Please select number<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"More than 12\">More than 12<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 15px\">Have you ever been a member of the armed forces?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"IfMemberOfArmy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"I am active military\" \/><span class=\"wpcf7-list-item-label\">I am active military<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"I am inactive military\" \/><span class=\"wpcf7-list-item-label\">I am inactive military<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"I am a veteran\" \/><span class=\"wpcf7-list-item-label\">I am a veteran<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"I have a family member who is active military\" \/><span class=\"wpcf7-list-item-label\">I have a family member who is active military<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"I have a family member who is inactive military\" \/><span class=\"wpcf7-list-item-label\">I have a family member who is inactive military<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"I have a family who is a veteran\" \/><span class=\"wpcf7-list-item-label\">I have a family who is a veteran<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"None of these apply to me\" \/><span class=\"wpcf7-list-item-label\">None of these apply to me<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"Choose not to answer\" \/><span class=\"wpcf7-list-item-label\">Choose not to answer<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"IfMemberOfArmy[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n<div><\/br><\/div>\n<label style=\"margin-top: 15px\">What is your highest level of education?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"EducationLevel\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"EducationLevel\"><option value=\"\">Please select your answer<\/option><option value=\"Less than a high school diploma\">Less than a high school diploma<\/option><option value=\"High school diploma or equivalent(GED)\">High school diploma or equivalent(GED)<\/option><option value=\"Some college\">Some college<\/option><option value=\"Technical college or Associate Degree\">Technical college or Associate Degree<\/option><option value=\"Bachelor&#039;s Degree\">Bachelor&#039;s Degree<\/option><option value=\"Master&#039;s Degree\">Master&#039;s Degree<\/option><option value=\"PhD\">PhD<\/option><option value=\"Other (certificate)\">Other (certificate)<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 20px\">Are you satisfied with the amount of education you have ?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"currentUseProduct\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currentUseProduct\"><option value=\"\">Please select your answer<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 15px\">What is your current employment status? (Please select all that apply)<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"employment-Status\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"employment-Status[]\" value=\"Employed full or part time\" \/><span class=\"wpcf7-list-item-label\">Employed full or part time<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"employment-Status[]\" value=\"Unemployed and looking for work\" \/><span class=\"wpcf7-list-item-label\">Unemployed and looking for work<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"employment-Status[]\" value=\"Unemployed and not looking for work\" \/><span class=\"wpcf7-list-item-label\">Unemployed and not looking for work<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"employment-Status[]\" value=\"On disability\" \/><span class=\"wpcf7-list-item-label\">On disability<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"employment-Status[]\" value=\"Student\" \/><span class=\"wpcf7-list-item-label\">Student<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"employment-Status[]\" value=\"Retired\" \/><span class=\"wpcf7-list-item-label\">Retired<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"employment-Status[]\" value=\"Other (please describe)\" \/><span class=\"wpcf7-list-item-label\">Other (please describe)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"employment-Status[]\" value=\"Choose not to answer\" \/><span class=\"wpcf7-list-item-label\">Choose not to answer<\/span><\/label><\/span><\/span><\/span>\n<div><\/br><\/div>\n<label style=\"margin-top: 20px\">Are you satisfied with your current employment status?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"currentUseProduct\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currentUseProduct\"><option value=\"\">Please select your answer<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 15px\">What is your annual household income?<\/label>\n<label style=\"color: red\">(Attention: Your household income is the total amount of gross income generated <\/label>\n<label style=\"color: red\">by the individuals\nliving within your household.)<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"IncomeAmt\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"IncomeAmt\"><option value=\"\">Please select amount<\/option><option value=\"No income\">No income<\/option><option value=\"Under $10,000\">Under $10,000<\/option><option value=\"Between $10,001 and $20,000\">Between $10,001 and $20,000<\/option><option value=\"Between $20,001 and $30,000\">Between $20,001 and $30,000<\/option><option value=\"Between $30,001 and $40,000\">Between $30,001 and $40,000<\/option><option value=\"Between $40,001 and $50,000\">Between $40,001 and $50,000<\/option><option value=\"Between $50,001 and $60,000\">Between $50,001 and $60,000<\/option><option value=\"Between $60,001 and $70,000\">Between $60,001 and $70,000<\/option><option value=\"Between $70,001 and $80,000\">Between $70,001 and $80,000<\/option><option value=\"Between $80,001 and $90,000\">Between $80,001 and $90,000<\/option><option value=\"Between $90,001 and $100,000\">Between $90,001 and $100,000<\/option><option value=\"Above $100,000\">Above $100,000<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 20px\">Are you currently satisfied with the support you are receiving around your recovery?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"currentSupport\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currentSupport\"><option value=\"\">Please select your answer<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 20px\">How would you rate your current physical health?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"physicalHealth\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"physicalHealth\"><option value=\"\">Please select your answer<\/option><option value=\"Bad\">Bad<\/option><option value=\"Okay\">Okay<\/option><option value=\"Good\">Good<\/option><option value=\"Great\">Great<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 20px\">How would you rate your current mental health?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mentalHealth\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"mentalHealth\"><option value=\"\">Please select your answer<\/option><option value=\"Bad\">Bad<\/option><option value=\"Okay\">Okay<\/option><option value=\"Good\">Good<\/option><option value=\"Great\">Great<\/option><option value=\"Choose not to answer\">Choose not to answer<\/option><\/select><\/span>\n<label style=\"margin-top: 20px\">What are you most proud of accomplishing since you started recovery?<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Accomplishment\"><textarea cols=\"40\" rows=\"10\" maxlength=\"700\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Accomplishment\"><\/textarea><\/span>\n<div><\/br><\/div>\n<p style=\"margin-top: 20px\">Telephone Recovery Support phone calls are made by trained and open-minded staff and \nvolunteer members.  However, if there is a specific group of people you feel more comfortable talking to such as gender and racial group, please describe. Please note that we do our best, however we cannot always honor your requests due to staff and volunteer availability.<\/p>\n<div><\/br><\/div>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phoneSupport\"><textarea cols=\"40\" rows=\"10\" maxlength=\"700\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"phoneSupport\"><\/textarea><\/span>\n<div><\/br><\/div>\n<div style=\"border-style: solid; padding: 5px; background-color: white\">\n<p>The purpose of the disclosure authorized in this consent it to: provide telephone 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 (HIPPA), 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. This consent expires automatically as follows:<\/p>\n<ol style=\"font-weight: 500\">\n  <li>I grant permission for a staff member or volunteer from ECI to call me at the above phone number and address to support me in my recovery.<\/li>\n<li>Each time the ECI volunteer calls, he\/she\/they 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, and other resources).<\/li>\n<li>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.<\/li>\n<li>If at any time I decide not to take part in this program, I will call ECI at 612-564-9289 or tell the volunteer when he\/she\/they calls<\/li>\n<\/ol>\n<\/br>\n\n<span style=\"font-weight: 500\"> I authorize Minnesota Recovery Connection (MRC) to place a phone call to me on a weekly basis at the number(s) I provided<\/span>\n<\/br>\n<div style=\"margin-top: 15px; margin-bottom: 15px\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"IAuthorized-YorN\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"IAuthorized-YorN[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n<label style=\"color: red\" >ATTENTION: If you check YES box, submit button will appear<\/label><\/div>\n<\/div>\n<\/br>\n<\/div>\n<\/div>\n<\/div>\n<div data-id=\"group-928\" data-orig_data_id=\"group-928\"  data-class=\"wpcf7cf_group\"> \n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/div><\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"129\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Contact Information Your contact and recovery information helps us provide better recovery support.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_uag_custom_page_level_css":"","footnotes":""},"class_list":["post-988","page","type-page","status-publish","hentry"],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false},"uagb_author_info":{"display_name":"abdulw","author_link":"https:\/\/empowercommunityinitiative.org\/?author=1"},"uagb_comment_info":0,"uagb_excerpt":"Contact Information Your contact and recovery information helps us provide better recovery support.","_links":{"self":[{"href":"https:\/\/empowercommunityinitiative.org\/index.php?rest_route=\/wp\/v2\/pages\/988","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/empowercommunityinitiative.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/empowercommunityinitiative.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/empowercommunityinitiative.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/empowercommunityinitiative.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=988"}],"version-history":[{"count":3,"href":"https:\/\/empowercommunityinitiative.org\/index.php?rest_route=\/wp\/v2\/pages\/988\/revisions"}],"predecessor-version":[{"id":992,"href":"https:\/\/empowercommunityinitiative.org\/index.php?rest_route=\/wp\/v2\/pages\/988\/revisions\/992"}],"wp:attachment":[{"href":"https:\/\/empowercommunityinitiative.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=988"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}