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Home
About
Mission Statement and History
Leadership and Board of Directors
Financial Report
News
Photo Gallery
Services
Services Offered
Accepted Insurance
Meeting Schedule
Program Applications
Residential Drug Treatment
Partial Hospitalization Program (PHP) + Intensive Outpatient Program (IOP)
Peer Support Services
How You Can Help
Employment
Job Application
Resident Advocate Posting
Contact Us
Subscribe to our Newsletter
Community Resources
Store
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Indicates required field
B.Riley Application for Treatment Services
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
CareSource
Molina
United Healthcare
Buckeye
Humana
AmeriHealth Caritas
Insurance Pending
No Insurance
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
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