B. Riley House
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B. Riley Drop-In Center
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Half-Way House
Three-Quarter Living
Intensive Outpatient Program
Peer Recovery Services
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We are currently accepting applications for three-quarter living house. Anyone applying to live in the house is required to submit this completed application prior to interviewing. YOU must be clean & sober a minimum of thirty (30) days and successfully completed a residential treatment program/half-way living program that was thirty (30) days or longer with evidence of participation. A minimum payment of $360.00 is required to move-in and an additional $40.00 the Friday following move-in (total rent is ($400.00) that includes all utilities).
Personal Information:
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Indicates required field
Name
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First
Last
What are your pronouns
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She/Her/Hers
He/Him/His
They/Them/Theirs
Other
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Sexual Orientation
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Lesbian
Gay
Bisexual
Queer
Heterosexual
Asexual
Questioning
Other
We have a 0% tolerance for discrimination or prejudice toward gender identity and sexual orientation.
If other, explain:
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Gender
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Female
Male
Transgender Male
Transgender Female
Gender Fluid
Agender
Non-Binary
Intersex
We have a 0% tolerance for discrimination or prejudice toward gender identity and sexual orientation.
Current living situation
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In your own words, explain current living situation
Martial Status
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Single
Married
Partnered
Divorced
Widowed
Significant Other
Prefer not to answer
Own a vehicle
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Yes
No
Utilize drop down box
Year/Make/Model
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Valid drivers license
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Yes
No
Utilize drop down box
Driver's License Number
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Recovery Information:
Do you indentify as
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Alcoholic
Drug Addict
I Don't Know
Date of last of use
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Drugs of Choice
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Currently/recently in treatment? Yes/No
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Yes or No answers please
Name & location of facility
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Did you complete successfully? Yes/No
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Discharge Date
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Name & number of counselor
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How do you plan on staying clean and sober?
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Do you attend 12-step meetings
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Yes
No
Not my thing
Who referred you to B. Riley 3/4 living?
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Do you have a sponsor? Yes/No
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Have you ever lived in recovery residence? Yes/No
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Name and location of house
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Why do you want to live at B. Riley Recovery House?
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Employment information:
Are you employed?
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Yes
No
Actively seeking Employment
If yes, name and location of employer
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Current monthly income
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What other types of work have you done?
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Special Skills/Trainings
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If no, how long since last employed?
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Are you willing/able to get a job within 30 days?
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Are you willing/able to be self-supporting?
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Will someone else be helping you pay rent of depost?
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Name
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First
Last
[object Object]
Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Legal Information:
List pending charges/cases/warrants
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Currently on probation or parole
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Parole
Probation
Inactive Probation
No parole or probation
Probation/Parole officer name and number
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Are you a registered sex offender?
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Have you been convicted of arson?
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Medical Information
List all medical/psychiatric conditions
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List all current medications
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Describe any injuries or disabilities
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Are on on medically-assisted treatment
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Suboxone
Methadone
Vivitrol
None
Emergency Contact:
Name at least two
Name
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First
Last
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Relationship
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Phone Number
*
Relationship
*
Document Upload:
Please provide the following:
1.) Assesment
2.) Certification of Completion of Treatment
3.) Release of Information for other Care Providers
(i.e., case managers, probation officers, counselors, etc.)
.
Upload File
*
Max file size: 20MB
Upload File
*
Max file size: 20MB
Upload File
*
Max file size: 20MB
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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
