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Bridging The Gap

We will accept all requests from anyone coming out of any type of facility who has a problem with alcohol.

To arrange for a Bridging the Gap contact, fill out the requested information below and click the submit button.

Your application will be forwarded to the BTG volunteer in your home area and they in turn, will

contact you before your discharge date. Please provide complete information on how you can be

reached at your facility and/or home. Phone numbers are vital!

Remember…all information provided on this form will be held in the strictest of confidence. It will

be used only to find a temporary BTG contact volunteer for you. Please let your counselor or an official with your organization know that you have requested to have contact with a Bridging The Gap volunteer.

REQUEST FORM

    Date

    Name

    Age  

    Sex - Male   Female (It is important that we match men/men and women/women)

    Special Needs:   

Tell us how to get in touch with you:

    Home Address:

Street 
City   State   Zip
Phone

Facility Name

             Rehabilitation Unit -     Correction Facility -

Client Mail Address (at the facility):

Street 
        City   State   Zip

    Facility Phone

    Discharge Date

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Copyright © 2008 - Area 76 Alcoholics Anonymous. All rights reserved.
Revised: May 13, 2008.

 

 

 

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Copyright © 2007 Area 76 Alcoholics Anonymous
Last modified: May 02, 2008