Suffolk Intergroup Bridging the Gap – Temporary Contact Request Form
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Name (First and Last): *
Gender: *
Facility you are coming from:
Age Range: *
Preferred Language:
 *
Phone Number (Cell or Landline):
Email Address:
Contact # while in Treatment Facility (if different than above):
Discharge Planning Counselor's Name & Phone Number:
Proposed discharge date: *
MM
/
DD
/
YYYY
Your Cell # or Daytime Phone # upon discharge if different that above:
Place you will go after Facility - County: *
Place you will go after Facility - Town/City: *
Place you will go after Facility - Province or State: *
Place you will go after Facility - Zip or Postal Code:
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