Florida Residential Application
Name
*
First Name
Last Name
Current Address. If none, please write "N/A" or leave blank.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Would you like to receive future electronic communications from B. Riley House?
*
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Gender
*
Please Select
Male
Female
Trans Male
Trans Female
Gender Fluid
Binary
Non Binary
Agender
Other/Prefer Not To Mention
Preferred Pronouns
*
Please Select
He/Him/His
She/Her/Hers
They/Them/Theirs
Other/Prefer not to mention
Sexual Orientation
*
Please Select
Gay
Lesbian
Bisexual
Queer
Heterosexual
Asexual
Questioning
Other/Prefer not to mention
Do you have insurance? If so, who is your provider? If no insurance, write "none".
*
Drug(s) of Choice
*
Alcohol
Heroin
Crack/Cocaine
Crystal meth
GHB
Ketamine
Barbiturates
Sedatives
Other
How many times in treatment?
Please Select
0
1-3
4-5
More than 5x
Medically Assisted Treatment
Please Select
Suboxone
Methadone
Vivitrol
Antabuse
None
Have you been tested for Tuberculosis within the last six (6) months?
Please Select
Yes
No
I don't know
Please list any medication(s) you currently take. If none, please write "N/A" or leave blank.
Special Circumstances
Recent Surgery
Diabetes
Asthmatic
High Blood Pressure
Schizophrenia
Bi-polar
Anxiety
Depression
Schizoaffective
Hepatitis A, B, and/or C
Pancreatitis
Panic Disorder
ADHD/ADD
Other
How did you hear about us?
Please Select
Referral from a Healthcare Provider
Referral from a Counselor or Therapist
Word of Mouth (Family/Friends)
Social Media (Facebook, Instagram, etc.)
Internet Search (Google, Bing, Yahoo, etc.)
B. Riley House Website
Community Event or Outreach
Grindr Advertisement
LGBTQ+ Support Groups
Partnership with Another Organization
Flyers/Posters
Previous Client Recommendation
Other
If applicable, referring Agency and Counselor's name and number
If coming from a residential treatment program, please upload the Release of Information (ROI), Discharge Summary, and/or Aftercare Plan below:
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Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
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