Ohio Peer Support Application

Ohio Peer Support Application
Name

First NameLast Name
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?
How did you hear about B. Riley House?
Date of Birth

MonthDayYear
Date
Social Security Number
Gender
Preferred Pronouns
Sexual Orientation
Current Address. If none, please write "N/A" or leave blank.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Medically Assisted Treatment
Please list any medication(s) you take
List all medical and/or psychiatric conditions
Recovery Journey Information
Date of last use

MonthDayYear
Date
Drug(s) of Choice

AlcoholHeroinCrack/CocaineCrystal MethGHBKetamineBarbituratesSedativesOther
Currently in treatment?

YesNo
If currently in treatment, name and location of facility
If currently in treatment, name and number of Counselor
How do you plan on staying clean and sober?
Employment Information
Currently employed?

YesNoActively seeking employment
If yes, name and location of current employer
Legal Information
If applicable, list pending charges, cases, and/or warrants
Currently on provation/paraole?

ProbationParoleInactive probationNeither probation or parole
If on probation and/or parole, name and number of assigned officer
Registered sex offender?

YesNo
Ever been convicted of arson?

YesNo
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Application Acknowledgement
Please provide any of the following:

1.) assessment
2.) certification of completion of treatment
3.) release of information (ROI) for other care providers (i.e., case managers, probation officers, counselors, etc.)
File Upload

Cancelof
Signature
Today's Date

MonthDayYear
Date
Should be Empty:

Ohio Peer Support Application

Recovery Journey Information

Employment Information

Legal Information

Emergency Contact

Application Acknowledgement