B.Riley Sober House
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HALF-WAY HOUSE
Three Quarter Living
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B.Riley Half-Way House Application:
Name
*
First
Last
Today's Date
*
Email
*
Drugs of Choice
*
Select One
Marijuana
Alcohol
Crack/Cocaine
Heroin
Crystal Meth
GHB
Ketamine
Barbiturates
Sedatives
Other
Phone Number
*
Date of Birth
*
How many times in treatment
*
Select One
0
1-3
3-5
More than 5x
Social Security Number
*
Insurance Information
*
Select One
Medicaid
Medicare
Insurance pending
Non-Insured
Other
Medically-Assisted Treatment
*
Select One
Suboxone
Methadone
Vivitrol
Antabuse
None
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
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
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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
Home
Services
About
Updates
Contact
HALF-WAY HOUSE
Three Quarter Living