B. Riley House - B.Riley House

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

B. Riley House Application for Treatment Services
Ohio Location

* Indicates required field

Name *

First

Last

Today's Date *

Email *

Phone Number *

Date of Birth *

Social Security Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Insurance Information *

List all medication you currently take *

Medically-Assisted Treatment *

How many times in treatment *

Gender *

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

Sexual Orientation *

Gay Lesbian Bisexual Queer Heterosexual Asexual Questioning Other

Drugs of Choice *

Alcohol Heroin Crack/Cocaine Crystal Meth GHB Ketamine Barbiturates Sedatives Other

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

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

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 None

If applicable; Referring agency and Counselor name and number *

Would you like to receive future electronic communications from B. Riley House? *

Yes No

If coming from a residential treatment program, please upload the Release of Information (ROI), Discharge Summary, and Aftercare Plan.

Upload File *

Max file size: 20MB

Submit

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B. Riley House - Cleveland, Ohio
2121 West 117th Street
Cleveland, Ohio 44111
(216) 417-4831

The Rose House - Miami, Florida
5951 Northeast 1st Avenue
Miami, Florida 33137
(786) 620-8008