Suffolk Intergroup Bridging the Gap – Temporary Contact Request Form
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Name (First and Last) *
Gender *
Facility *
Age Range *
Preferred Language
 *
How can we contact you? ( Phone # to call/text ) *
How can we contact you? ( Email ) *
Contact # while in Treatment Facility
OR Contact # for Discharge Counselor *
Discharge Planning Counselor's Name *
Proposed discharge date: *
MM
/
DD
/
YYYY
You Cell # or Daytime Phone # upon discharge *
Place you will go after Facility - Town/City *
Place you will go after Facility - County *
Place you will go after Facility - Zip or Postal Code *
Place you will go after Facility - Province or State *
Submit
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