Referral Request

Recovery Housing Scholarship Applicants and Recipients may complete this form to be connected to Peer Recovery Support (Certified Recovery Specialist) and/or Case Management Services or call us BRIDGE LINE: 855-2-THEBRIDGE (855-284-3274)

About You

Your 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 Contact

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Best Time to Call You(Required)

If this is not your private phone number, please let us know who we are calling to reach you

Would you like help connecting with:(Required)

Peer-to-Peer Support (A Certified Recovery Specialist)

Case Management

If 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 seeking

Your Comments/Questions(Required)

Date Services are Needed

Let us know when you will commence services with the support provider(s)