B.Riley Sober House
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Name
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First
Last
Today's Date
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Email
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Drugs of Choice
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Select One
Marijuana
Alcohol
Crack/Cocaine
Heroin
Crystal Meth
GHB
Ketamine
Barbiturates
Sedatives
Other
Phone Number
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Date of Birth
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How many times in treatment
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0
1-3
3-5
More than 5x
Social Security Number
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Insurance Information
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Medicaid
Medicare
Insurance pending
Non-Insured
Other
Medically-Assisted Treatment
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Suboxone
Methadone
Vivitrol
Antabuse
None
Address
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Line 1
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City
State
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Country
List all medication you currently take
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Gender
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Trans-Female
Trans-Male
Female
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Gender Fluid
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Have you been tested for Tuberculosis within the last 6 months
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Yes
No
I think I should get tested
I don't know
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
ADD
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