B. Riley House
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B.Riley Half-Way House Application:
Name
*
First
Last
Today's Date
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Email
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Drugs of Choice
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Marijuana
Alcohol
Crack/Cocaine
Heroin
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GHB
Ketamine
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Other
Phone Number
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Date of Birth
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How many times in treatment
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1-3
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Social Security Number
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Insurance Information
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Medically-Assisted Treatment
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Suboxone
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Address
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List all medication you currently take
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Gender
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Have you been tested for Tuberculosis within the last 6 months
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I think I should get tested
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Sexual Orientation
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Gay
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Heterosexual
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If applicable; Referring agency and Counselor name and number
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If coming from a residential treatment program please upload ROI, Discharge Summary, and Aftercare Plan
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Special Circumstances
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Recent Surgery
Diabetes
Asthmatic
High Blood Pressure
Schizophrenia
Bi-polar
Anxiety
Depression
Schizoaffective
Hepatitis A, B, or C
Pancreatitis
Panic Disorder
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Home
About
Mission and History
Board and Staff
Financials
B. Riley Drop-In Center
Services
Half-Way House
Three-Quarter Living
Intensive Outpatient Program
Peer Recovery Services
Donate
Contact
