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Name
*
First
Last
Phone
*
Email
*
Date Of Birth
*
MM slash DD slash YYYY
Desired Move In Date
*
MM slash DD slash YYYY
Clean / Sober Date
*
MM slash DD slash YYYY
Drug Of Choice
*
Heroin
Other Opiates
Alcohol
Benzos
Cocaine
Marijuana
Other
Drug Of Choice Other
Do You Take Any Of The Following Prescription Medications?
*
Suboxone (is an approved medication)
Methadone (is an approved medication, provided Client doesn't posses more than 1 day's dose and doesn't 'nod' or seem intoxicated)
Any Opiate EXCEPT Suboxone including: Vicodin, Norco's, Oxy/Hydro: morphine/morphone/contin etc.
Any Stimulant including: Adderall, Ritalin, etc.
Any Benzodiazepine including: Xanax, Valium, Klonopin, Ativan etc.
NONE OF THE ABOVE
Other
Other - Do You Take Any Of The Following Prescription Medications?
Are you In Treatment Or Attending IOP/PHP?
*
Yes
No
Which Treatment or Recovery Center (IOP)? (Or None)
*
Who Referred You To Bridges
*
Other Information
Email
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Bridges Sober Living Chicago, Located In The Logan Square & Avondale Neighborhoods. Website by
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.
