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(216) 441-2496

Recovery Housing

Approved by Ohio Recovery Housing

Jordan Recovery Housing Application

First Name

Last Name

Address

Phone

Date of Birth

Social Security Number

Drugs of Choice

How many times have you recieved treatment? *

One

Two

Three

Four

Five

Medically Assisted Treatment *

Yes

SPECIAL CIRCUMSTANCES *

Recent Surgery

Diabetes

Asthmatic

High Blood Pressure

Schizophrenia

Bi-polar

Anxiety

Depression

Schizoaffective

Hepatitis A, B, or C

Pancreatitis

Panic Disorder

Other

IF APPLICABLE; REFERRING AGENCY AND COUNSELOR NAME AND NUMBER

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If coming from a residential treatment program please upload ROI, Discharge Summary, and Aftercare Plan Upload supported file (Max 15MB).

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Empowering Female Survivors of Human Trafficking, Drug Addiction, Re-entry and Behavioral Health.

Email: info@jordan4change.com

Phone: (216) 441-2496

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