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MAKE A REFERRAL / TAKE ASSESSMENT FORM
I want to
First name
Last name
DOB
Gender
Race
Any court involved issues?
Yes
No
IF YES: Do you need support? What kind?
Do you use drugs or alcohol?
Yes
No
If yes, what kind(s)?
How much do you use per day?
Do you use alone or with others?
Have you received treatment for a substance use disorder?
Yes
No
IF YES: for how long?
What were the dates?
Longest period of time in treatment
Are you interested in hearing about treatment options at the Bridge Clinic?
Yes
No
Would you be interested in attending a support group?
Yes
No
IF YES: What kind of support groups?
What times work for you?
Additional comments
Phone number to contact you
Date
Select an option
*
Male
Female
Other
Select an option
*
18-25
26-35
36-45
Other
What city do you live in?
Are you interested in learning about treatment options for drugs and alcohol?
*
Yes
No
Maybe
Would you be interested in attending a support work group?
*
Yes
No
If you answered yes, what kind of group?
What are the best dates or times for a group?
Register
Thanks for registering to our event. See you there!
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