California House – Men’s Residence
Troy House – Men’s Residence
Richmond House – Women’s Residence
Date Of Birth
Desired Move In Date
Clean / Sober Date
Drug Of Choice
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 - Do You Take Any Of The Following Prescription Medications?
Are you In Treatment Or Attending IOP/PHP?
Which Treatment or Recovery Center (IOP)? (Or None)
Who Referred You To Bridges
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