A Bridge To Recovery

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Admissions
Download Forms

Downloading and completing the following forms saves time when you visit our office. Email us at admin@abridgetorecovery.com if you have problems finding the form you need.

The following forms are in Adobe PDF format.

•  Complete Intake Packet - Ridgeland
•  Partial Intake Packet - Ridgeland
•  Dr. Deborah Gross Intake Packet
•  Consent Form
 
Assessment

Everyone coming to A Bridge to Recovery is screened by professional staff to determine their appropriateness for treatment. All information remains confidential. Individuals admitted to the program while under the care of a medical or psychological professional may continue that treatment when appropriate. We provide alcohol/drug abuse assessments utilizing industry standard testing instruments. Accurate results help to ensure our clients receive the proper level of care, increasing their chances of success. Test results are accepted by outside entities (i.e.; legal, custody, employers, etc.)

Below is our confidential initial online assessment. Upon completion, someone from A Bridge to Recovery will contact you.

Assessment

Everyone coming to A Bridge to Recovery is screened by professional staff to determine their appropriateness for treatment. All information remains confidential. Individuals admitted to the program while under the care of a medical or psychological professional may continue that treatment when appropriate. We provide alcohol/drug abuse assessments utilizing industry standard testing instruments. Accurate results help to ensure our clients receive the proper level of care, increasing their chances of success. Test results are accepted by outside entities (i.e.; legal, custody, employers, etc.) Below is our confidential initial online assessment. Upon completion, someone from A Bridge to Recovery will contact you.

 

Referral Information
How did you hear about our treatment facility?

Person Completing Form

Name (first, middle, last):
Relationship to patient:
Phone 1:
Phone 2:
Address:
Email address:

Insurance Company

Insurance Company:
Insurance Phone #:
Insurance Policy #:
Insurance Group #:
Plan:
Effective Date:

Insured Party

Insured Name:
Relation to Patient:
Social Security #:
Date of Birth:

Services:

Please tell us what services you would like us to check for.

IOP
Individual
Mental Health
Substance Abuse
Sex Addiction
Eating Disorders
Psychiatrist

Client Information

Name
SS # DOB Gender male
female
Address
City State Zip Code
Phone Email    

Alcohol/Drug Treatment History

Dates of treatment  Where?

Did you complete the
treatment program?

 Type of treatment
(residential, outpatient, inpatient, etc)
Yes No
Yes No
Yes No
Yes No

Current Medications

Name of Medication Dosage & Frequency Prescribing Physician Reason meds are taken

List all surgeries you have had including elective and cosmetic surgeries:

Surgery Date of Surgery Doctor Who Performed Surgery Reason for Surgery

Drug(s) of Choice & Usage Patterns

Name of Drug Age of first use Date of last use How much/often

Medical & Psychiatric Information

Have you ever had a problem with gambling?
Have you ever had an eating issue or eating disorder?
What do you struggle with most in a relationship?
Have you ever had a problem with intimacy or relationship issues?
Do you feel that your sexual behavior is or has ever been a problem?

Sexual History:
Are your sexually active?
Sexual Orientation:

Buy Big Purchases:
Do you overspend or buy ticket purchases, and feel remorseful later?
Do you often make purchases only to return them?
Do you shop to "feel better"?

Criminal History:
Have you ever been arrested?

Medical History & Hospitalization

- If Yes, Please Explain:

Active Infections: - If Yes, Please Explain:
Pregnant or Suspected Pregnancy:

Miscarriages, Abortions, Adoptions:
If Yes, Please Explain:

Diabetes: - If Yes, Please Explain:
Weight Change (loss or gain): - Amount:
Liver Problems: - If Yes, Please Explain:
Blood Pressure: - If Yes, Please Explain:
Short Term Memory / Long Term Memory
If Yes, Please Explain:
Appetite Disturbance: - If Yes, Please Explain:
Sleep Disturbance: - If Yes, Please Explain:
STD's or Unprotected Sex: - If Yes, Please Explain:

What is your current living situation?

Current Marital Status:

If Divorced, how many times: Explain:

Do you have any children?
If Yes, how many and what are their ages?

Any custody issues? - If Yes, Please Explain:

Education / Job Training:

Highest Degree Obtained:

Military Experience: - If Yes, Please Explain:

Learning, Reading, or Writing Deficits:

Are you currently employed? - If No, Why Not?

If currently unemployed, for how long have you been unemployed?

If you are employed, where are you employed?

Is your job in jeopardy due to your behavior or issues?

Is your employer aware that you have a problem?

Have you been experiencing any job or school difficulties?
If Yes, Please Explain:

 
To which location should this form be sent? 
 
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Insurance

Insurance We Honor

In Network Insurance

  • Advanced Health Systems (AHS)
  • Aetna
  • Blue Cross Blue Shield of Mississippi
  • Blue Cross Blue Shield Out of State Plans
  • Cigna Behavioral Health
  • ComPsych
  • First Choice Health Plan of Mississippi
  • First Health
  • Galaxy Health Network
  • GEHA
  • Life Synch
  • Magellan Behavioral Health
  • Mississippi Physicians Care Network
  • PPOUSA
  • Three Rivers Provider Network
  • United Behavioral Health (UBH)
  • USA Managed Care Network
  • Value Options

A Bridge to Recovery is in the process of becoming providers for a number of other companies so if your carrier is not listed it does not mean we do not accept your insurance. A number of carriers will do what is called a "Single Case Agreement" which allows a "Out of Network" provider to see a client and will pay the in network rate.



Insurance Coverage Form

Use the following secure form to send us information about your insurance coverage.
NOTE: Fields marked with an asterisk are required to verify coverage.

Insurance We Honor

In Network Insurance

  • Advanced Health Systems (AHS)
  • Aetna
  • Blue Cross Blue Shield of Mississippi
  • Blue Cross Blue Shield Out of State Plans
  • Cigna Behavioral Health
  • ComPsych
  • First Choice Health Plan of Mississippi
  • First Health
  • Galaxy Health Network
  • GEHA
  • Life Synch
  • Magellan Behavioral Health
  • Mississippi Physicians Care Network
  • PPOUSA
  • Three Rivers Provider Network
  • United Behavioral Health (UBH)
  • USA Managed Care Network
  • Value Options

A Bridge to Recovery is in the process of becoming providers for a number of other companies so if your carrier is not listed it does not mean we do not accept your insurance. A number of carriers will do what is called a "Single Case Agreement" which allows a "Out of Network" provider to see a client and will pay the in network rate.



Insurance Coverage Form

Use the following secure form to send us information about your insurance coverage.
NOTE: Fields marked with an asterisk are required to verify coverage.

YOUR INFORMATION (not necessarily the prospective patient)

*Name:
*Email:
Address:
City:
State:
Zip:
Phone (home):
Relation:
Services - Please tell us what services you would like us to check for.

 





   

PROSPECTIVE PATIENT

*Name:
*Address:
*City:
*State:
*Zip:
*Phone (home):
Phone (business):
*Date of Birth:
*Social Security #:
Comments:
Please let us know about any special circumstances and how we should contact you and/or the prospective patient.
   

INSURANCE COMPANY
*Insurance Company:
*Insurance Phone #:
*Insurance Policy #:
*Insurance Group #:
Plan:
Effective Date:
   

INSURED PARTY

*Insured Name:
*Relation to Patient:
*Social Security #:
*Date of Birth:
*Employer:
Still Employed:
Length:
Term Date:
   
To Which Loaction Should This Form Be Sent?

   
I am providing this information for use only by A Bridge to Recovery. Any information given will be kept private and confidential.
 
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Bookstore Recommendations

Hazelden’s Book Store

CLICK HERE for Hazelden Books and Resources

Here is a list of recommended resources.

•  Receive Today's Gift a daily e-mail meditation
•  Hazelden Books and Categories
•  Hazelden medallions listing
•  Hazelden's Jewelry and Gifts feature page.
•  Twenty-Four Hours a Day book
•  The Little Red Book
•  Language of Letting Go book
•  Addictive Thinking -Second Edition
•  Alcoholics Anonymous The Big Book
•  Codependent No More
•  Treatment Resources for the providers
•  The Twelve Step Prayer Book
•  Keep It Simple
•  Touchstones
•  A Woman's Spirit
•  Alcoholism and Drug Use Assessment/Evaluation Is it addiction?
•  Betrayal Bonds
•  Out of the Shadows
•  Silently Seduced
•  Life Without Ed
•  Eating Out of the Light of the Moon
 
Self Help Groups

Adult Children of Alcoholics

Adult Children of Alcoholics is a Twelve Step, Twelve Tradition program of women and men who grew up in alcoholic or otherwise dysfunctional homes. We meet with each other in a mutually respectful, safe environment and acknowledge our common experiences. We discover how childhood affected us in the past and influences us in the present ("The Problem"). We take positive action. By practicing the Twelve Steps, focusing on "The Solution", and accepting a loving Higher Power of our understanding, we find freedom from the past and a way to improve our lives today.

 

Mississippi Links

AA of Mississippi
Area 37 (Mississippi) Web Site of Alcoholics Anonymous

NA of Mississippi
NA is a nonprofit fellowship or society of men and women for whom drugs had become a major problem. If you are new to our program please come to a meeting and see us. Narcotics Anonymous is a program that works. We help each other stay off of drugs and become productive members of society again. After coming to NA we realized we were sick people. We suffered from a disease from which there is no known cure. It can, however, be arrested at some point, and recovery is then possible.

National Counsel on Alcoholism and Drug Dependence of Mississippi

The National Council on Alcoholism and Drug Dependence of the Central Mississippi Area was established in 1949 as the Jackson Committee for Education on Alcoholism. Volunteers provided all services until the first Executive Director was hired in the 1950's as the community's needs for services grew. During the last 50 years, the Council has grown in size and in the number of services provided. Funding is made possible through United Way, private donations and grants.

Mississppi Alanon Family Groups
 




Ridgeland Location:  361 Towne Center Blvd. Suite 1300 Ridgeland, MS 39157  |  Phone: 601-977-9353  |  info@abridgetorecovery.com
Brandon, MS - Florence, MS - Flowood, MS - Hinds County, MS - Jackson, MS - Madison, MS - Madison County, MS - Rankin County, MS - Richland, MS - Ridgeland, MS

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