Bridging The Gap Treatment Form

ALCOHOLICS ANONYMOUS
HMB AREA 48
TREATMENT FACILITIES
BRIDGING THE GAP
TEMPORARY CONTACT REQUEST FORM

The Bridging the Gap (BTG) program is a state wide service provided by Alcoholics
Anonymous (AA) and coordinated by B.J.G. Committees of AA. It is designed to
help alcoholics in a treatment program make the transition to the AA program.
As a client requesting an AA contact, please be aware of the following:

  • AA only offers a path to recovery from Alcoholism
  • A contact person will write or phone you after this form is processed. The two of you will make arrangements to meet as soon as possible. This Contact will help you get to your first AA meetings and introduce you to other AA members in your community.
  • The contact person serves as a vital link between you and the outside
    AA group.

We need you to supply the following information in order to get you the proper
contact. This information will be kept confidential.
Please complete all lines!

    Your Name

    Your Email

    Name of Client

    Gender of Client
    MaleFemale

    Current Mailing Address of Client

    Street:
    City:
    State:
    Zip:
    Phone:
    Address where client will be residing if different

    Street
    City:
    State:
    Zip:

    Anticipated Release Date:


    Would you prefer a contact who speaks another language?
    YesNo

    If yes, which language?

    You may print and mail this form to the address below, or simply hit submit and it will be emailed to the Bridging the Gap chair.

    Mailing address:
    Bridging the Gap/Pre-release Program
    c/o HMB Area Association
    118 Polar Plaza #114
    Amsterdam, NY 12010