Request a Referral to Recovery Support Referral Request Recovery Housing Scholarship Applicants and Recipients may complete this form to be connected to a Recovery House, Peer Recovery Support (Certified Recovery Specialist) and/or Case Management Services About YouConfirmation of Participation in Bridge to Recovery Housing Program(Required) I am a Bridge Housing Scholarship Applicant or Recipient*Referrals to Support Services are only available for Bridge to Recovery Housing Scholarship Applicants and RecipientsYour Name(Required) First Last Your Address Street Address Address Line 2 City ZIP Code How Can We Reach You?We will contact you to discuss your needs and connect you with local support services.Preferred Method of ContactEmailPhoneYour Email Address(Required) Email Address Confirm Email Address Your Phone(Required)Best Time to Call You(Required)Select A Time12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pmIf this is not your private phone number, please let us know who we are calling to reach youWould you like help connecting with:(Required) Peer-to-Peer Support (A Certified Recovery Specialist) Case Management Select AllIf you are a current or future resident of a specific Recovery House: Recovery House Name Street City How can we Help?Please let us know more about your needs and the Recovery support services you are seekingYour Comments/Questions(Required)Date Services are Needed MM slash DD slash YYYY Let us know when you will commence services with the support provider(s)
