B. Riley House

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Home
About
Services
Program Applications
How You Can Help
Employment
- Job Application
- Resident Advocate Posting
Contact Us
- Subscribe to our Newsletter
- Community Resources
Store

* Indicates required field

B.Riley Application for Treatment Services

Name *

First

Last

Today's Date *

Email *

Drugs of Choice *

Phone Number *

Date of Birth *

How many times in treatment *

Social Security Number *

Insurance Information *

Medically-Assisted Treatment *

Address *

Line 1

Line 2

City

State

Zip Code

Country

List all medication you currently take *

Gender *

Trans-Female Trans-Male Female Male Gender Fluid Binary Non-Binary Agender Prefer not to mention

Have you been tested for Tuberculosis within the last 6 months *

Yes No I think I should get tested I don't know

Sexual Orientation *

Gay Lesbian Bisexual Queer Heterosexual Asexual Questioning Other

If applicable; Referring agency and Counselor name and number *

If coming from a residential treatment program please upload ROI, Discharge Summary, and Aftercare Plan

Upload File *

Max file size: 20MB

Special Circumstances *

Recent Surgery Diabetes Asthmatic High Blood Pressure Schizophrenia Bi-polar Anxiety Depression Schizoaffective Hepatitis A, B, or C Pancreatitis Panic Disorder ADD Other

Submit