Policies * Procedures Rules * Regulations Requirements & Responsibilities

Size: px
Start display at page:

Download "Policies * Procedures Rules * Regulations Requirements & Responsibilities"

Transcription

1 The Big Packet Policies * Procedures Rules * Regulations Requirements & Responsibilities Inside this packet you will find answers to common questions and details about procedures and policies.

2 We appreciate the opportunity to introduce ourselves and look forward to meeting you and answering any questions you might have after you go through this packet. We have tried to be as thorough as possible in the details of our program and what to expect at The Arches but we know you may still have some unanswered questions after you complete the packet. Please write them down and we will be make sure we get all of your questions answered before you make a decision about whether The Arches is a good fit for you. We are a transitional recovery community called The Arches. Our mission is to provide a safe, structured 12 step living program to help men and women transition from early recovery back into productive and healthy lives. The Arches was founded and is run by individuals in recovery who are passionate about sobriety and working with other s to help them realize the miracle of living life clean and sober. We are a community structured program based on the 12 Steps of Alcoholic Anonymous. This is an important element to the success of our program. The process of recovery involves many people who build a support system to keep each other accountable and on the path to permanent recovery. Through this process it is possible to learn to live clean, sober, productive lives. The structure and accountability within our program is all designed to add support for the work you will do with your sponsor through the process of your 12 step recovery program. We work closely with our clients to provide that level of support and advice that is so critical and necessary in the early stages of recovery.

3 The good news is this process does work if you are willing to take suggestions and do the work. We provide the structure and if you are committed to staying sober the changes and miracles you are getting ready to experience are amazing. The Arches is a great fit for some people but it might not be a good fit for others. The goal is permanent sobriety at The Arches and our policy is ZERO tolerance. Through an interview process we assess the willingness, character and overall needs for a potential client and determine if you will be a good fit for our program. In the event you are not a good fit we will offer referrals to other programs that might provide a level of care more suitable to your particular needs. If you are looking for permanent sobriety and everything you have read so far seems like a good fit for you then please continue.

4 Here s what we need from you.. Minimum Requirements for Admission 1. Commitment to stay at least 6 months. You may stay longer. 2. Complete abstinence from all mind & mood altering substances. This includes illegal drugs, alcohol, prescription drugs (certain medical exceptions can be made), or any other substance used to alter your mind or mood. We do drug & alcohol screening 2-3 times per week, and all screens are lab verified for accuracy and tampering. We ensure that you will have a safe and sober place to recover, and we discharge immediately with zero tolerance for a failed drug or alcohol screen. Our screens are very comprehensive, and include all illegal drugs, prescription drugs that we do not allow, ETG & ethanol tests for alcohol, and all head shop type substances including spice, bath salts, etc. 3. You must be willing to get a "sponsor", which is a person who will guide you through the 12 Steps of recovery. We expect everyone to have, at very least, a temporary sponsor within 1 week. The importance of working with a competent sponsor is vital to good recovery and the sooner you find someone to start guiding you through the steps the better your chances of staying sobriety. We will help you learn what to look for in a sponsor, and assist you in finding one if needed. 4. Willingness to learn how to stay clean & sober through the 12 Steps of Recovery. Active participation in all groups, step-work with your sponsor, and attendance of outside 12 Step meetings is mandatory. 5. Complete willingness to follow all rules and directions. The Arches is a structured living environment that provides all residents with the opportunity to transition back into life by living with structure and accountability. We will discharge anyone who does not follow the rules, for the safety and well-being of those who are serious about long term recovery. 7. You must either have a job, be actively seeking employment (this will be verified), be attending an outpatient program, or be participating in community service or volunteer work during the day. Part of the structure of recovery and transitioning into life is learning to fill our day with worthwhile and productive activities. Even if your program fees are being paid by family or outside resources, you will be required to be productive and self-sufficient at The Arches. If you are unemployed, you will have three weeks to find a job (all program fees are still due on time). 8. Willingness to focus on yourself. Putting relationships on hold for a minimum period of 30 days is suggested.

5 9. Willingness to attend mandatory meetings. There are two mandatory meetings that are at specific times and days of the week. Additionally, you are required to attend a 12 Step meeting of your choice every day. For the first 60 days you will be required to attend a 12 step meeting every day at There may also be other mandatory meeting, retreats, and functions throughout the year.

6 Policy for the Payment of Program Fees A one-time admission fee of $125 is due at intake. There are two ways to pay the program fees at The Arches: Weekly - $175 per week, due every Friday. Your first week will be due at intake. - OR - Monthly - $700 per month (cheaper overall than weekly), due on the 1st of each month. Your first month will be due at intake. **Program fees must be on time. Friday Fees Must Be Collected by 4:00pm * Monthly fees must be collected by 4:00 pm on the first of the month. * If Fees are not collected by 4:00pm there will be an additional late fee of $25 * If fees are not collected by 9:00 pm on day they are due you will be terminated from The Arches Program** Program fees can be paid by cash, check, money order, or online via credit card. If you wish to pay online, please provide us with your address, and we will send you an invoice that you can pay with your debit or credit card. We use PayPal for our online payments, but you do not have to have a PayPal account to pay with your credit/debit card. There is a 3% processing fee for paying online. We use Paypal and are charged a 3% fee for using the Paypal service. The 3% processing fee is only charged to cover this cost Online Payments need to be made by the appropriate payment deadlines. If processing fees or late charges are not included in the online payments, they are still due and will be collected from the clients. The Arches Meeting Schedule There are two meetings that are mandatory each week. You must schedule all other activities or work schedules around these meetings. There are some exceptions made from time to time and case by case. In addition to these house meetings you are required to attend 1 (one) AA meeting each day, and meet in person with your sponsor at least once a week. The Arches Mandatory Meeting Program: Wednesday 7:30pm, Check In & AA Meeting (Unit 901) Sunday 7:30 pm, Check In & House Meeting (Unit 901)

7 Legal Advocacy / Letters of Residency or Acceptance Once you have been accepted in our program, we are happy to provide you with any documentation you may need for probation or parole, legal cases, food stamps, or any other reason. If needed, we will also send a staff member to appear in court on your behalf to explain our program and help with your legal case. There is a $100 fee for our staff s time, and we may ask you to help cover travel expenses if more than 20 miles travel is required.

8 Program Rules & Policies The following actions will result in immediate discharge from the program: (In other words here s what NOT to do): Being under the influence of alcohol and/or drugs. Refusal to submit to requested drug screen. Possession/distribution of alcohol/drugs. Possession of any drug paraphernalia. Possession of pornography, or use of computers, DVD, or TV to view pornography. No texting of sexually inappropriate messages, calling pornographic sex talk numbers or engaging in any of form of pornographic behavior will be permitted. No Online Date Site activity will be allowed Possession of weapons or wielding any object as a weapon. Threats either verbal or physical, overt acts of violence and/or fighting. Property destruction or altering the physical construction of the premises. Being unaccountable, discrepancies in time off premises and/or violation of curfew. Dishonesty, giving false information on intake paperwork, theft, unusual behavior and/or any form of criminal activity. Failure to comply with rules and/or staff directions.

9 Food Residents are responsible for purchasing their own food. We will assign you cabinet space for dry goods, and the refrigerator/freezer is shared. In a shared living environment, it is an exercise in cooperation and respectfulness to ensure that each person eats only the food they buy. If the community wishes to have a community meal and purchase food as a group, then everyone should agree on what is to be bought and to work together to contribute equally in purchasing, preparation and cleaning up after every meal. There will be no tolerance for arguments about food learning to coexist with respect and care of one another is the key to living in any group environment. Transportation You are responsible for your own transportation expenses. Our residences are located conveniently to public transportation. People with vehicles in our program work together to offer rides to help those who do not have vehicles. If you receive a ride from another resident, you are required to help pay for gas expenses. Bikes are allowed and must be stored on the back patios, and security of these is not the responsibility of The Arches or the staff. Residents who want to have their vehicles must complete the Driving Contract section of this application, and all Resident s vehicles must have current tags, registration, and insurance. Vehicles will be parked in designated areas and security of vehicles is your responsibility. There will not be storage of inoperable vehicles on the premises and all vehicle maintenance must be performed off the premises. Family Involvement Addiction is a family disease, and it affects everyone involved in the life of an addict. Many families/friends do not understand the disease of addiction, and often times will actually hurt their loved one s chances for recovery through codependence and enabling, when they are only trying to help. We can help clarify for them what types of support will actually benefit the addict/alcoholic, and what will only enable the cycle to continue. You will be required to sign a release for us to talk to your family as well as your physician, therapist, probation/parole officer, or any other persons the staff deems necessary.

10 Medications Residents must be capable of maintaining and administering their own medications. A list of all medications you take will be completed in this packet and kept in your file. If your medications change, you must immediately notify the House Manager. There are certain medications that are not allowed at The Arches, and you should speak to the staff if you have any questions regarding medication you are taking. Failed drug screens due to prescribed medications we are not aware of, are grounds for immediate discharge. There are a number of medications that are allowed the best policy is to let the staff know what medications you are taking, no matter what they are. Then there are no questions or situations that arise with a violation of policy. Buddy System All new residents will be on a buddy system for a minimum of the first two weeks at The Arches. This means that any time you are not on our property, you will be with another member of the program. The only exception is if you are going to work. The buddy system is a great way for new residents to get to know their new housemates, and to integrate into The Arches community. It also provides accountability and safety while you are settling in. You may process to come off the buddy system after you have been at The Arches a full two weeks. Processing is done in your Community Meeting. The requirements to come off the buddy system are: 1. Integration into the community (you have gotten to know everyone and are not isolating) 2. You have a 12 Step sponsor and have begun working the steps. 3. You have a job, or have demonstrated that you are doing an intensive job search. (If you are in school or an outpatient program, that fulfills the requirement) 4. You have not broken any rules 5. You have completed and processed a Community Contract (the form can be found in this packet)

11 Electronics TV s, Phones, Stereos, Computers Residents are permitted to carry cell phones. Clock radios are permitted in the rooms but must be maintained at a sound level that is considerate of your roommates and not heard outside of the residence. WIFI is provided in the residences. Computer use is a necessity in today s world but it can also be a form of isolation and a gateway into abusive behavior. Viewing pornography and excessive usage of computer systems will not be permitted. Watching movies on your computer in the bedrooms will not be allowed. Loaning your computer to a roommate is done so at your own discretion and is not considered a good policy to practice. The Arches does not recommend or is liable for any issues surrounding your computer systems. The Arches provides a TV for use in the common area. TV s are not allowed in the bedrooms. The use of PlayStation, Xbox and other gaming systems are permitted at the discretion of the House Manager. *IMPORTANT* The TV is to be shared among the roommates. There will be no controlling of the TV by one person. Continued violations of this behavior will not be tolerated. Personal Belongings Any valuables such as money, jewelry, stereos, pictures, etc. are the responsibility of the resident, and should be secured at all times. The Arches is not responsible or liable for your personal belongings. Residents are not permitted to share clothing, personal property, loan money, and/or drive another resident s vehicle. Any belongings left in a The Arches residence after discharge will not be kept for more than 72 hours and will be disposed of at the discretion of The Arches staff. Recreational Activities There is a workout room and tennis courts in the complex. Available after 30 days residents will be able to utilize the facilities and participate in classes at Total Boxing, a kickboxing school located in Roswell, Georgia.

12 WHAT DOES IT MEAN TO PROCESS AN ISSUE/REQUEST? Living a sober life is challenging, and for most a new experience. We often lack the insight and decision making skills needed to make responsible life choices that will support our recovery. Processing or discussing issues and requests in Community Meeting serves as a means to get constructive feedback and guidance from fellow community members. Residents are required to process issues related to; employment, relationships, leave requests, sponsorship, recovery plan, goals, and any other issue/topic that the resident is advised to address by staff. Accountability As a resident of The Arches, you are expected to account for all your time away from the residence. As a resident, you are expected to be at work or your daily routine, (i.e. IOP, school, volunteer work, community service, etc.) during the scheduled times. You must notify the House Manager of any changes in your schedule such as, sick leave, vacation, time off, early dismissal, etc. Open communication and accountability are essential to success in our program. Sickness If you are ill, inform your House Manager as soon as possible. You are expected to report your chemical dependency to any medical person you see personally. You are also expected to report to your House Manager any person you will be seeing medically, before the appointment, and bring any requested paperwork to the House Manager promptly. This includes dentists, eye doctors, ER visits, etc. Your House Manager must approve any prescribed drug BEFORE you fill ANY prescriptions. Curfew The curfew at The Arches is 10:00pm, Sunday-Thursday, and 11:00pm Friday & Saturday. Please plan ahead so that you are not late for any reason. Curfew is checked every night and absolutely no tardiness is acceptable. If a curfew extension is needed for any reason, a TL form must be filled out and processed at your community meeting.

13 Receiving Mail & Residency Questions There will be times when you will be asked for proof of residency, such as; applying for social security card, food stamps, outpatient counseling services, job applications, etc. As a resident of The Arches, you are considered to be a participant in a social services program and not a permanent resident of the physical address where you are currently living. When listing a current address you must use the following mailing address: TW Enterprises c/o YOUR NAME 8343 Roswell Road - # 358 Atlanta, GA There will be times when you are asked for a proof of residency and this can be obtained by requesting a letter from the staff verifying your current address and participation in the program. Residents are to be advised that if this policy is not followed and mail is received indicating utilization of the residence address and/or an attempt to establish The Arches residence as a permanent address will result in immediate discharge and possible criminal charges for fraud. Also, note that all mail received at the residence address for unauthorized individuals or a resident who has been discharged, will be marked incorrect address and returned to the local post office. Employment All residents of The Arches are required to be employed within 3 weeks of admission. The only exceptions to this are full-time students, individuals on disability, individuals attending an I.O.P. program, or situations pre-approved by the staff. Your job must not conflict with curfew and required meetings. Residents are not permitted to serve alcohol or work in any environment that would be considered dangerous to their sobriety. All job opportunities must be processed in Community Meeting and approved by the staff prior to accepting employment with any employer. Residents are not permitted to terminate a job without first processing the issue in Community Meeting and have the approval of the staff.

14 Drug & Alcohol Screens All residents are required to submit to random drug and alcohol screens (including breathalyzers). Random drug screens will be conducted at least twice a week. When a resident is informed of a drug screen, he/she will have 1 hour to comply with the request. The Arches uses Calloway Labs to perform on-site drug screens, which are monitored and lab confirmed. Calloway will collect your insurance information, as well as a list of all medications you are taking, at the time of the first drug screen. All screens are processed through your insurance as lab work, and they are in-network with all insurance carriers. You should never have a co-pay or any additional charges for our drug screens, however you may receive a statement that will say This is NOT a bill, and some charges may count against your deductible. A positive drug screen or refusal of a requested drug screen will result in immediate discharge. Dating / Fraternizing You must have a willingness to focus on yourself if you want to be successful. We have a strict No Fraternization policy for a minimum of 60 days. This means no dating, hanging out, or spending time with members of the opposite sex. Additionally, there will be absolutely no fraternizing with members of the opposite sex who are current residents of The Arches program. If you are already in a relationship, you must be willing to put it on hold and focus on your recovery for a minimum of 30 days. At 60 days you may process dating privileges in community meeting, and receive feedback from the staff and your peers. We prefer you be at least on your 5th step to process dating privileges. Personal Cleanliness and Chores You are responsible for keeping your residence in a neat and orderly fashion. This means you will keep your bed made at all times, carpets vacuumed, floors swept, and clothing clean and put away. You are also expected to keep the bathroom and kitchen clean after each use. Staff has the right to inspect the premises, including your dressers and closets, at any time. You will also be assigned chores each week in order to help keep the residence as a whole in top condition. Overall cleaning day is Saturday morning before you leave for the day but maintaining a level of cleanliness through the week is mandatory.

15 Dress Code Proper dress is expected at all times. This means no over revealing clothing will be allowed for men or women. No pants hanging down below the underwear level. No excessively revealing tops. No short shorts. Clothing (shirts, pants or appropriate shorts) must be worn at all times in the residences. Pets Residents are not permitted to have pets while at The Arches, and no pets should visit our property without prior approval from the staff. This is out of consideration to everyone in the program as well as the terms of our lease. Visitors There are absolutely no visitors permitted on the premises except for The Arches staff and approved volunteers without specific permission from the Director or House Manager. Absolutely no one (including family) is allowed in the residences without staff approval. If this occurs, it is grounds for immediate termination and a direct violation of the contract for services with The Arches. This is for the safety and comfort of all of our residents. Emergencies The Arches staff is on call for emergencies 24 hours a day, 7 days a week. Residents should contact the staff immediately in case of any house emergency, medical emergency, risk or harm to (or by) another resident, relapse or suspected relapse, or a resident s violation of curfew. Failure to do so is grounds for discharge, because everyone s safety is a top priority and will not be compromised. There are evacuation plans and fire extinguishers located throughout all of our residences, as well as smoke alarms and marked exits. If you still have questions about anything at all, we are glad to answer them! You can call any one listed below directly (these are their cell phones) to ask any questions you may have: House Managers: Directors: Todd Wilson or- Debbie Cohen

16 The following pages contain important information about our Privacy Practices, and your rights & responsibilities as a resident of The Arches. Please read them carefully! NOTICE OF PRIVACY PRACTICES The Arches is required by law to maintain the privacy of certain health care information about our residents. The law also requires health care providers like The Arches to give you a Notice like this one and to follow its standards. The Arches and your Protected Health Care Information As a part of our daily activities, The Arches may need to use and disclose (share) your protected health care information for several purposes without first getting your written approval. Those purposes include: The Arches may contact you based upon your protected health care information. For example The Arches may call to arrange your appointments, provide you with information about new medications, treatments, benefits and services that are available to you. The Arches may provide information to government officials who oversee health care or are working on threats to public safety. Your personal identity will remain confidential unless written permission is provided. The Arches may report Protected Health Care Information regarding unsafe diseases, neglect, abuse, and other crimes, according to laws in specific circumstances per The Arches Informed Consent Form. The Arches will exercise diligence in providing maximum protection of your personal identity where possible. The Arches may provide information to licensed researchers who are under strict rules regarding how they use and disclose protected health care information. Those researchers, as an example, may use the information about patients with your condition for a study to improve ways to combat disease. Your personal identity will remain confidential. No other uses and disclosures of your protected health care information will occur without your written authorization. And, if you sign an authorization, you have the right to cancel it at any time.

17 HOW TO OPT OUT You have the right to opt out of authorized uses and disclosures at any time. This opt out by law will not apply to disclosures that are legally permitted, disclosures we make to companies that perform services on our behalf, or companies that process or service transactions you request or authorize. Once your request is received, The Arches will, in a reasonable amount of time, stop disclosures. You may always contact us for assistance if you wish to revoke your opt out election. You may direct us not to make disclosures (other than disclosures permitted by law) by writing a formal request to rescind disclosures. This letter can be mailed to the attention of: Todd Wilson, Privacy Officer The Arches 8343 Roswell Road - # 358 Atlanta, GA Rights Regarding Your Protected Health Care Information: Under the law, you have several rights that The Arches is committed to upholding. Those rights include: The right to request restrictions on some of the ways The Arches uses and discloses your information. These restrictions can go beyond the restrictions already in the law. The Arches is not responsible for consequences that may occur legally, financially, or professionally if The Arches is restricted from communicating or advocating on your behalf. However, The Arches may not always agree to implement these additional restrictions. The right to receive confidential communications. However, this right is not absolute and may be restricted on the patient s treatment plan. The right to inspect and get copies of your health care information held by The Arches by making a request in writing. The Arches however, may charge a reasonable fee to cover only the cost of providing this information. Staff may restrict access to some information based on clinical or psychiatric conditions.

18 The rights to request that The Arches amend or correct any information in your record. To make such a change, The Arches will ask you to make the request in writing with the reason you want your record changed. The Arches may not always agree to such requests. If you have any questions or complaints about the way The Arches handles your protected health care information or if you believe your privacy rights have been violated, contact The Arches Privacy Officer, at (404) or in person. You can also contact the Secretary of the U.S. Department of Health and Human Services. Please note that there will be not retaliation against you for filing a complaint or making requests regarding your health care information, or for disagreeing with The Arches related decisions. The Arches may need to change its privacy practices from time to time. Before making such changes however, The Arches will modify this Notice and begin distributing it to patients when they are treated by The Arches. These new practices will then apply to all information held by The Arches. At any time, anyone has a right to get a paper copy of the latest version of this Notice by asking Todd Wilson, Privacy Officer. CLIENT RESPONSIBILITIES Provision of Information Clients have the responsibility to provide, to the best of their knowledge, accurate and complete information about presenting problem(s), identifying information, past treatment(s), medical issues, medication usage, legal issues, or other matters asked by the staff of The Arches. They have a responsibility to report any changes of condition, or relapse to the staff of The Arches. They have a responsibility to report any violation of rules and regulations, of their own or of other clients, to the staff of The Arches. Clients are responsible for making it known whether they clearly comprehend a contemplated course of action and what is expected of them.

19 Compliance with Instruction Clients are responsible for following the recommended recovery plan established by The Arches and themselves. This may include instructions by personnel not employed by The Arches such as other healthcare personnel, other mental health professionals, parole officers, probation officers, or other officers of the Court. Clients are responsible for keeping appointments, attending scheduled groups and activities, with The Arches and outside agencies. Clients are responsible for giving sufficient notice as described by The Arches or outside agencies, when they are unable to meet their prior commitments. Refusal of Services / Therapeutic Advice Clients are responsible for their own actions when they refuse therapeutic advice or fail to follow the suggestions of staff or volunteers as it relates to their recovery. Payment of Fees Clients are responsible for meeting financial obligations to The Arches as agreed with the Business Office. The Arches - Rules and Regulations Clients are responsible for following all rules and Regulations of The Arches. Respect and Consideration Clients are responsible for being considerate of the rights of other clients, other residents of the recovery residence and to The Arches staff. Clients are responsible for noise control within their residence. Clients are responsible for being respectful of the property of other clients, other residents of the house, the neighborhood, the home itself, and of The Arches. Property Issues Under no circumstances are the residents of The Arches to go to the Leasing Office for anything. All questions, repair problems or other property situations are to be discussed with the Directors only.

20 Confidentiality Clients are responsible for maintaining the confidentiality of their peers. Clients are responsible for complying with Federal Regulations regarding confidentiality and cannot disclose the presence of any other client, current or past, enrolled in The Arches. Clients are responsible for not disclosing any information they may hear regarding any other client enrolled in The Arches Program. CLIENT RIGHTS As a resident of The Arches you have the right to: 1. Clients DO have a RIGHT to be fully informed of their rights and responsibilities as a client of The Arches. 2. Clients DO have a RIGHT to the least restrictive environment, to socialize and participate in recreational activities, appropriate to their treatment and the RIGHT to move about freely as safety permits. Special conditions may apply for clients who are mandated to The Arches as a condition to parole, probation, bond, or if mandated to the House Arrest Program. 3. Clients DO have a RIGHT to wear their own clothing and to keep their own possessions, religious items, or other symbolic items, unless the property interferes with their recovery or the recovery of other clients. 4. Clients DO have the RIGHT to be informed of the Rules and Regulations of The Arches, the schedule and procedures that they are to follow as client of The Arches. Clients DO have a right to be informed of what is expected concerning their conduct as a client of The Arches. They are entitled to information concerning The Arches grievance resolution policies for the initiation, review, and resolution of their complaint(s). 5. Clients DO have a RIGHT to know the identity and professional status of the individuals providing services to them. 6. Clients DO have a RIGHT to confidentiality, except in matters concerning child or elder abuse, threats of violent to another human being, threats of homicide to another human being, and suicide threats. 7. Clients DO have a RIGHT to consult with an attorney concerning the documentation used by The Arches.

Holdrege Nebraska. Unity Houses. Providing a safe and affordable living environment for adults recovering from addiction.

Holdrege Nebraska. Unity Houses. Providing a safe and affordable living environment for adults recovering from addiction. Holdrege Nebraska Unity Houses Providing a safe and affordable living environment for adults recovering from addiction. Females Only For admission information contact: 835 South Burlington Av Suite 115

More information

St. Croix County Drug Court Program. Participant Handbook

St. Croix County Drug Court Program. Participant Handbook St. Croix County Drug Court Program Participant Handbook Updated: May 2014 To The St. Croix County Drug Court Program. This Handbook is designed to answer your questions and provide overall information

More information

MENDING HEARTS HALF-WAY HOUSE RULES REVISED 4-13

MENDING HEARTS HALF-WAY HOUSE RULES REVISED 4-13 MENDING HEARTS HALF-WAY HOUSE RULES REVISED 4-13 Restoring Women, Reclaiming Lives In order to help you become more comfortable with your surroundings, we have listed the following rules and regulations

More information

NEXT STEP RECOVERY WOMEN S PROGRAM Introduction to Program Standards

NEXT STEP RECOVERY WOMEN S PROGRAM Introduction to Program Standards NEXT STEP RECOVERY WOMEN S PROGRAM Introduction to Program Standards Next Step Recovery House for Women provides women recovering from alcohol and substance-abuse dependency the time to acquire the necessary

More information

No Personal Checks! Only Cash, Cashiers check or Money order made out to Joan Maynord will be accepted

No Personal Checks! Only Cash, Cashiers check or Money order made out to Joan Maynord will be accepted DOVE RIDGE CLEAN AND SOBER/TRANSITIONAL LIVING TENANCY AGREEMENT This agreement is made and entered this day of 2013, By and between Dove Ridge (Clean & Sober Transitional Living, and Joan Maynord and

More information

RESIDENTIAL FACILITY, 122 W. Hill Street, Champaign, Illinois

RESIDENTIAL FACILITY, 122 W. Hill Street, Champaign, Illinois RESIDENTIAL FACILITY, 122 W. Hill Street, Champaign, Illinois DAILY ACTIVITIES: The schedule during your treatment stay includes groups, classes, lectures, 12 step meetings, and other recovery related

More information

Involuntary Commitments and Psychiatric Hospitals

Involuntary Commitments and Psychiatric Hospitals Involuntary Commitments and Psychiatric Hospitals What does this mean to You and Your Loved Ones? 515 28 3/4 Road Grand Junction, CO 81501 970.263.4918 WestSpringsHospital.org M-1: INVOLUNTARY COMMITMENT

More information

Addiction Treatment Strategies

Addiction Treatment Strategies Patient Registration Legal Name First Middle Last Birth Date Address Street City State Zip Phone(s) Home Cell Work Is it ok to contact your cell? Yes No SSN Email (Used for appointment reminder) Known

More information

Handbook for DWI Court Participants

Handbook for DWI Court Participants Handbook for DWI Court Participants Important names and numbers: My Attorney: Phone # My Probation Officer: Name: Phone # My Treatment Program: Phone # Drop Line # Your Assigned color is Visit the web

More information

Helping People Find Their Way Back

Helping People Find Their Way Back Frequently Asked Questions Information for families, friends and loved ones The Healing Place of Richmond 700 Dinwiddie Ave. Richmond, VA 23224 804.230.1217 www.thprichmond.org Helping People Find Their

More information

PALM HOUSE RECOVERY CENTER RECOVERY RESIDENCE RESIDENT HANDBOOK

PALM HOUSE RECOVERY CENTER RECOVERY RESIDENCE RESIDENT HANDBOOK PALM HOUSE RECOVERY CENTER RECOVERY RESIDENCE RESIDENT HANDBOOK 11/2014 Palm House Recovery Centers 2 Mission Statement Palm House Recovery Centers is a non-profit organization whose purpose is to provide

More information

Georgia Accountability Court Adult Felony Drug Court. Policy and Procedure Manual

Georgia Accountability Court Adult Felony Drug Court. Policy and Procedure Manual Georgia Accountability Court Adult Felony Drug Court Policy and Procedure Manual Contents Policy and Procedure Manual: Adult Felony Drug Court Overall purpose...3 Mission Statement...4 Adult Drug Court

More information

THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission.

THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission. THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission.org PDP INTAKE APPLICATION Thank you for taking this important

More information

INTAKE APPLICATION. TPH Intake Application 083110 JAC - 1/5

INTAKE APPLICATION. TPH Intake Application 083110 JAC - 1/5 THE POTTER S HOUSE Attention Intake Coordinator 655 Potter's House Road, Jefferson, GA 30549 Phone: (706) 543-8338, Extension 5103; Fax: 706-546-9929 tphintake@atlantamission.org, www.atlantamission.org

More information

Resident Rights in Nursing Homes

Resident Rights in Nursing Homes Resident Rights in Nursing Homes Nursing home residents have patient rights and certain protections under the law. The nursing home must list and give all new residents a copy of these rights. Resident

More information

Outpatient Services. Partial Hospitalization Program (PHP) & Intensive Outpatient Program (IOP) Patient Handbook. Bringing Life Into Balance

Outpatient Services. Partial Hospitalization Program (PHP) & Intensive Outpatient Program (IOP) Patient Handbook. Bringing Life Into Balance Bringing Life Into Balance Outpatient Services Partial Hospitalization Program (PHP) & Intensive Outpatient Program (IOP) Patient Handbook PHP/IOP Patient Handbook Page 1 of 7 Confidentiality The confidentiality

More information

CITY OF ST. LOUIS JUVENILE DRUG COURT PARTICIPANT'S HANDBOOK

CITY OF ST. LOUIS JUVENILE DRUG COURT PARTICIPANT'S HANDBOOK CITY OF ST. LOUIS JUVENILE DRUG COURT PARTICIPANT'S HANDBOOK MISSION STATEMENT CITY OF ST. LOUIS JUVENILE DRUG COURT To provide an environment for court-supervised juveniles to become clean and sober and

More information

M ANHATTAN T REATMENT. Contents. Handbook. webready MTC. Guidelines and Program Information for Participants

M ANHATTAN T REATMENT. Contents. Handbook. webready MTC. Guidelines and Program Information for Participants M ANHATTAN T REATMENT C O U R T Welcome to MTC 3 What is MTC? 4 What s in it for me? 5 MTC Rules 6-8 STEP Phase Description and 9-14 Sanction Schedule Graduation 15 MTC Expectations 16-18 MTC Support Services

More information

STATEMENT OF PURPOSE

STATEMENT OF PURPOSE DRINKING PROBLEM? FOUNDATION HOUSE MEN S SOBER LIVING HOUSE FOR FUN AND FOR FREE NOT FOR PROFIT STATEMENT OF PURPOSE To provide an environment of sober and clean living by utilizing the spiritual principles

More information

New Perspective Counseling Services Child/Teen Intake Form

New Perspective Counseling Services Child/Teen Intake Form Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.

More information

YOUR RIGHTS RESPONSIBILITIES TO OUR PATIENTS. Patients and families come first. We are here to serve with respect, compassion, and honesty.

YOUR RIGHTS RESPONSIBILITIES TO OUR PATIENTS. Patients and families come first. We are here to serve with respect, compassion, and honesty. TO OUR PATIENTS YOUR RIGHTS & RESPONSIBILITIES Patients and families come first. We are here to serve with respect, compassion, and honesty. We will try to do our best today, and do better tomorrow. We

More information

Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center

Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Intensive Outpatient Program Participant Handbook Table Of Contents: Welcome..... Page 1 Introduction. Page 1 Staff Page 1 Informed

More information

SEBASTIAN COUNTY DRUG COURT. Client Handbook

SEBASTIAN COUNTY DRUG COURT. Client Handbook SEBASTIAN COUNTY DRUG COURT Client Handbook Page 1 Revised 6-26-2013 INTRODUCTION TO DRUG COURT You have been arrested for a felony crime and have been identified as a person who may have a drug problem.

More information

Downloadable Forms: Otsego County Chemical Dependencies Clinic. Client Handbook. Revised 04/10

Downloadable Forms: Otsego County Chemical Dependencies Clinic. Client Handbook. Revised 04/10 Downloadable Forms: Otsego County Chemical Dependencies Clinic Client Handbook Revised 04/10 OTSEGO CHEMICAL DEPENDENCIES CLINIC 242 Main St, 2 nd Floor Oneonta, New York 13820 Tel. (607) 431-1030 Fax.

More information

INTAKE APPLICATION. MSH PDP Intake Application 090210 AUM Page 1 of 5

INTAKE APPLICATION. MSH PDP Intake Application 090210 AUM Page 1 of 5 MY SISTER S HOUSE Attention Intake Coordinator 921 Howell Mill Road NW, Atlanta, GA 30318 Phone: (404) 367-2476; Fax: (404) 875-6675.atlantamission.org INTAKE APPLICATION Thank you for taking this important

More information

St. Mark s House Residential Detoxification. Client Guide

St. Mark s House Residential Detoxification. Client Guide Alcohol Services Leeds St. Mark s House Residential Detoxification Client Guide St Anne s Mission To support individuals to achieve their aspirations by providing services that promote dignity, independence,

More information

The Drug Court program is for addicted offenders. The program treats a drug as a drug and an addict as an addict, regardless of the drug of choice.

The Drug Court program is for addicted offenders. The program treats a drug as a drug and an addict as an addict, regardless of the drug of choice. Drug Court Handbook Mission Statement Drug Courts in the 7th Judicial District will strive to reduce recidivism of alcohol & drug offenders in the criminal justice system and provide community protection

More information

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Patient Name (please print): Welcome to the therapy services

More information

Tompkins County Treatment Court

Tompkins County Treatment Court Tompkins County Treatment Court TCTC At the Community Justice Center 312 North Cayuga Street Ithaca, New York 14850 TCTC: (607) 277-1455 Coordinator: (607) 274-7508 Ext. 114 Fax: (607) 272-0783 Handbook

More information

Polk Medical Center Notice of Privacy Practices

Polk Medical Center Notice of Privacy Practices Polk Medical Center Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

Floyd Healthcare Management, Inc. Notice of Privacy Practices

Floyd Healthcare Management, Inc. Notice of Privacy Practices Floyd Healthcare Management, Inc. Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

The PEER RECOVERY SPECIALIST provides peer mentoring, support and education during your stay.

The PEER RECOVERY SPECIALIST provides peer mentoring, support and education during your stay. Guild South and Maureen s House 318 2 nd St. N. South St. Paul, MN 55075 Staff Phone: 651-455-6800 Resident Phone: 651-450-1783 SERVICE AGREEMENT WELCOME TO GUILD SOUTH! We look forward to working with

More information

Mental Health Services

Mental Health Services Handbook of Consumer Rights Mental Health Services Consumer Services and Rights Protection 2007 This Book Belongs To: Table of Contents Handbook of Mental Health Consumer Rights... 2 Your Right To Be Informed

More information

Rights and Responsibilities of Patients

Rights and Responsibilities of Patients RIGHTS AND RESPONSIBILITIES OF PATIENTS Rights and Responsibilities of Patients Patient Rights and Responsibilities At Mayo Clinic, we are concerned that each patient entrusted to our care is treated with

More information

406 TH JUDICIAL DISTRICT sobriety treatment program Participation agreement

406 TH JUDICIAL DISTRICT sobriety treatment program Participation agreement 406 TH JUDICIAL DISTRICT sobriety treatment program Participation agreement The State of Texas vs. Cause# The 406 th Judicial District Drug Court Program is a drug intervention program. The program is

More information

2542 Bessie Street Delray Beach, FL 33444 Ph: 561-945-7560 Fax: 561-637-8525

2542 Bessie Street Delray Beach, FL 33444 Ph: 561-945-7560 Fax: 561-637-8525 THE LODGE PHILOSOPHY We at THE LODGE believe that every recovering person has a responsibility to themselves and to the community not to become or remain a burden to society. We believe that every person

More information

Policies & Procedures

Policies & Procedures 2.2 Drug Free Work Place Adopted 1.24.2003 Revised 3.28.2004; 5.26.2006; 3.2.2011 Reference: WAC 388.805.200(3) POLICY In accordance with "The Drug Free Workplace Act of 1988, The Healing Lodge prohibits

More information

8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078

8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078 Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd

More information

St. Mark s and Ashton House Residential Rehabilitation. Client Guide

St. Mark s and Ashton House Residential Rehabilitation. Client Guide Alcohol Services Leeds St. Mark s and Ashton House Residential Rehabilitation Client Guide St Anne s Mission To support individuals to achieve their aspirations by providing services that promote dignity,

More information

APPLICATION/ INFORMATION PACKAGE

APPLICATION/ INFORMATION PACKAGE APPLICATION/ INFORMATION PACKAGE We are glad that you are considering coming to LIFE Recovery. For your safety and well-being, we would like you to understand what our expectations are once you are admitted

More information

Garland s Christian Counseling Center

Garland s Christian Counseling Center Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave

More information

MAT Disclosures & Consents 1 of 6. Authorization & Disclosure

MAT Disclosures & Consents 1 of 6. Authorization & Disclosure MAT Disclosures & Consents 1 of 6 Authorization & Disclosure ***YOUR INSURANCE MAY NOT PAY FOR ROUTINE SCREENING*** *** APPROPRIATE SCREENING DIAGNOSES MUST BE PROVIDED WHEN INDICATED*** Urine Drug Test

More information

Plattsburgh City Court DRUG COURT HANDBOOK. Hon. Penelope D. Clute Drug Court Judge. Welcome to Plattsburgh City Court. Drug Court

Plattsburgh City Court DRUG COURT HANDBOOK. Hon. Penelope D. Clute Drug Court Judge. Welcome to Plattsburgh City Court. Drug Court Plattsburgh City Court DRUG COURT HANDBOOK Hon. Penelope D. Clute Drug Court Judge Welcome to Plattsburgh City Court Drug Court This Handbook is designed to: Drug Court Eligibility and Exclusionary Criteria

More information

Honolulu DWI Court Frequently Asked Questions

Honolulu DWI Court Frequently Asked Questions Honolulu DWI Court Frequently Asked Questions (Please note that content may be revised. Any revisions will be discussed with you.) Revised 3/26/14 1 How do I enter DWI Court? 1) Work with your lawyer to

More information

M ANHATTAN MISDEMEANOR T REATMENT

M ANHATTAN MISDEMEANOR T REATMENT M ANHATTAN MISDEMEANOR T REATMENT C O U R T Index Welcome to MMTC 3 What is MMTC? 4 What s in it for me? 5 MMTC Rules 6-8 MMTC Phase Description and 9-15 Sanction Scheme Graduation 16 MMTC Expectations

More information

NEW JERSEY. Downloaded January 2011

NEW JERSEY. Downloaded January 2011 NEW JERSEY Downloaded January 2011 SUBCHAPTER 4. MANDATORY RESIDENT RIGHTS 8:39 4.1 Resident rights (a) Each resident shall be entitled to the following rights: 1. To retain the services of a physician

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

More information

Julia Hughes Tabor, MA, LPC Licensed Therapist 2207 Delaney Drive Ste 107 Burlington, NC 27215 Phone: 336-684-9951 Fax 336-513-0554

Julia Hughes Tabor, MA, LPC Licensed Therapist 2207 Delaney Drive Ste 107 Burlington, NC 27215 Phone: 336-684-9951 Fax 336-513-0554 Julia Hughes Tabor, MA, LPC Licensed Therapist 2207 Delaney Drive Ste 107 Burlington, NC 27215 Phone: 336-684-9951 Fax 336-513-0554 Some things you should know About your therapist and Therapy: Since therapy

More information

Adult Drug Court Participant Handbook

Adult Drug Court Participant Handbook THE CIRCUIT COURT FOR MONTGOMERY COUNTY, MARYLAND Adult Drug Court Participant Handbook MY DRUG COURT INFORMATION My Case Manager s Name is: My Case Manager s Phone Number is: My Case Manager s Email address

More information

Rights for Individuals in Mental Health Facilities

Rights for Individuals in Mental Health Facilities HANDBOOK Rights for Individuals in Mental Health Facilities Admitted Under the Lanterman-Petris-Short Act C A L I F O R N I A D E P A R T M E N T O F Mental Health How to Reach Your Patients Rights Advocate

More information

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

COMMUNITY WEEKEND INTERVENTION PROGRAM

COMMUNITY WEEKEND INTERVENTION PROGRAM COMMUNITY WEEKEND INTERVENTION PROGRAM Payment to Charles Stebbins can be made by one of the following methods: Cashier Check or Money Order from a bank only OR Exact Cash at his Office NO PERSONAL CHECKS

More information

HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY

HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY HΨC HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY 5237 SUMMERLIN COMMONS BLVD, SUITE 116 FORT MYERS, FLORIDA 33907 PHONE: 239.274.PSYC (7792) FAX: 239.247.5344 Informed Consent for Financial Responsibility & Psychological

More information

PERSONAL RECOVERY PROGRAM INTAKE APPLICATION

PERSONAL RECOVERY PROGRAM INTAKE APPLICATION Attention: Intake Coordinator 1801 S. 35 th Ave Phoenix, AZ 85009 Phone: (602) 346-3360; Fax: (602) 233-1329 phoenixrescuemission.org PERSONAL RECOVERY PROGRAM INTAKE APPLICATION Thank you for taking this

More information

Brantford Native Housing Residential Support/ Addiction Treatment Program

Brantford Native Housing Residential Support/ Addiction Treatment Program Brantford Native Housing Residential Support/ Addiction Treatment Program Application Package Ojistoh House or Karahkwa House 318 Colborne Street East Brantford, ON N3S 3M9 (519) 753-5408 x 235 T (519)

More information

Client Rights Handbook. Your rights and responsibilities as a consumer of Access Family Services, Inc.

Client Rights Handbook. Your rights and responsibilities as a consumer of Access Family Services, Inc. Client Rights Handbook Your rights and responsibilities as a consumer of Access Family Services, Inc. Key Contacts Chief Executive Officer 704 521 4977 Chief Operating Officer 704 521 4977 President Southeastern

More information

Understanding Psychological Assessment and Informed Consent

Understanding Psychological Assessment and Informed Consent Understanding Psychological Assessment and Informed Consent You have taken the first step to feel more successful and empowered in your life by choosing to participate in a Psychological Assessment. Thank

More information

COLQUITT SUPERIOR COURT SUBSTANCE ABUSE/MENTAL HEALTH TREATMENT COURT PROGRAM

COLQUITT SUPERIOR COURT SUBSTANCE ABUSE/MENTAL HEALTH TREATMENT COURT PROGRAM COLQUITT SUPERIOR COURT SUBSTANCE ABUSE/MENTAL HEALTH TREATMENT COURT PROGRAM PARTICIPANT HANDBOOK for Drug Court Program Colquitt Superior Court Southern Judicial Circuit PROGRAM DESCRIPTION The Drug

More information

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Welcome to my office! Below is some information you may wish to read before your first appointment. Included

More information

Sterman Counseling and Assessment

Sterman Counseling and Assessment Information for Clients Welcome to Sterman Counseling and Assessment. We appreciate the opportunity to be of assistance to you. This packet answers some questions about therapy services. It is important

More information

Notice of Privacy Practices

Notice of Privacy Practices SHANNON LERACH, Ph.D. Licensed Clinical Psychologist PSY23705 243 N. Highway 101, Suite 16, Solana Beach, CA 92075 Telephone: (619) 817.5320 Fax: (858) 481.1674 Notice of Privacy Practices This Notice

More information

Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648

Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Problems in love and work, as well as troubling symptoms like depression and anxiety, often lead people to seek therapy.

More information

HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. This practice is required by law to

More information

July 2014 EDITION. Sanctuary Centers of Santa Barbara

July 2014 EDITION. Sanctuary Centers of Santa Barbara CO-OCCURRING DISORDERS INFORMATIONAL HANDBOOK July 2014 EDITION Sanctuary Centers of Santa Barbara 1 Table of Contents Welcome Message 2 Who s Who.3-4 Treatment Philosophy and Objectives 5-6 SCSB....7

More information

Hope In-Home Care CODE OF CONDUCT AND ETHICS

Hope In-Home Care CODE OF CONDUCT AND ETHICS Hope In-Home Care CODE OF CONDUCT AND ETHICS September 2014 Table of Contents A MESSAGE FROM OUR DIRECTOR... 3 INTRODUCTION TO THE CODE OF CONDUCT AND ETHICS... 4 ELEMENT 1: QUALITY OF CARE... 5 ELEMENT

More information

JEWISH FAMILY SERVICE NOTICE OF PRIVACY PRACTICES

JEWISH FAMILY SERVICE NOTICE OF PRIVACY PRACTICES Jewish Family Service takes pride in treating our clients and each other with respect and dignity. Protecting your health information is very important to us. We want you to have a clear understanding

More information

TABLE OF CONTENTS. Program Description... 1. DUI Court Supervision... 3. DUI Court Program Rules... 4. Program Fees... 7. Treatment Procedures...

TABLE OF CONTENTS. Program Description... 1. DUI Court Supervision... 3. DUI Court Program Rules... 4. Program Fees... 7. Treatment Procedures... DUI Court Program Participants Handbook Revised June 2011 TABLE OF CONTENTS Section Page Program Description... 1 DUI Court Supervision... 3 DUI Court Program Rules... 4 Program Fees... 7 Treatment Procedures...

More information

PERSONAL RECOVERY PROGRAM INTAKE APPLICATION

PERSONAL RECOVERY PROGRAM INTAKE APPLICATION A Ministry of Phoenix Rescue Mission PERSONAL RECOVERY PROGRAM INTAKE APPLICATION CLC Intake Application 121211 CLC Page 1 of 6 Attention Intake Coordinator 338 North 15 th Avenue, Phoenix, AZ 85007 Phone:

More information

Patient s Bill of Rights For Mental Health Services

Patient s Bill of Rights For Mental Health Services Patient s Bill of Rights For Mental Health Services When you apply for or receive mental health services in the State of Tennessee, you have many rights. Your most important rights are listed on these

More information

FREQUENTLY ASKED QUESTIONS REGARDING THE SALVATION ARMY ADULT REHABILITATION CENTER PROGRAM INTAKE

FREQUENTLY ASKED QUESTIONS REGARDING THE SALVATION ARMY ADULT REHABILITATION CENTER PROGRAM INTAKE FREQUENTLY ASKED QUESTIONS REGARDING THE SALVATION ARMY ADULT REHABILITATION CENTER PROGRAM INTAKE Q. What kind of clothes do I need to bring when I go to your program? A. Generally we prefer that you

More information

Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047

Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete

More information

SURGICAL CENTER FOR EXCELLENCE PATIENT INFORMATION

SURGICAL CENTER FOR EXCELLENCE PATIENT INFORMATION As a person with pain, you have the right to: SURGICAL CENTER FOR EXCELLENCE PATIENT INFORMATION PAIN CARE BILL OF RIGHTS Have your report of pain taken seriously and to be treated with dignity and respect

More information

Clay/Becker Veterans Treatment Court. Participant Handbook

Clay/Becker Veterans Treatment Court. Participant Handbook Clay/Becker Veterans Treatment Court Participant Handbook March 2014 THIS BOOK BELONGS TO: NAME: CD TX PROGRAM: COUNSELOR NAME: PHONE NUMBER: AFTERCARE: COUNSELOR NAME: PHONE NUMBER: MENTOR NAME: PHONE

More information

DUI... INSTANT CRIMINAL RECORD

DUI... INSTANT CRIMINAL RECORD DUI... INSTANT CRIMINAL RECORD TABLE OF CONTENTS Implied Consent How DUIs Are Handled p. 2 p. 2 I. DUI ADMINISTRATIVE PROCEDURES II. DUI COURT PROCEDURES A. Penalties B. First Offense Election C. IID License

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

NEW HAMPSHIRE. Downloaded January 2011 HE P 803.08 NURSING HOME REQUIREMENTS FOR ORGANIZATIONAL CHANGES.

NEW HAMPSHIRE. Downloaded January 2011 HE P 803.08 NURSING HOME REQUIREMENTS FOR ORGANIZATIONAL CHANGES. NEW HAMPSHIRE Downloaded January 2011 HE P 803.08 NURSING HOME REQUIREMENTS FOR ORGANIZATIONAL CHANGES. (a) The nursing home shall provide the department with written notice at least 30 days prior to changes

More information

SDC-League Health Fund

SDC-League Health Fund SDC-League Health Fund 1501 Broadway, 17 th Floor New York, NY 10036 Tel: 212-869-8129 Fax: 212-302-6195 E-mail: health@sdcweb.org NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION

More information

Independent Bank 230 W Main St Ionia, MI 48846 800.300.3193 www.independentbank.com ELECTRONIC FUND TRANSFER AGREEMENT AND DISCLOSURE

Independent Bank 230 W Main St Ionia, MI 48846 800.300.3193 www.independentbank.com ELECTRONIC FUND TRANSFER AGREEMENT AND DISCLOSURE 230 W Main St Ionia, MI 48846 800.300.3193 www.independentbank.com ELECTRONIC FUND TRANSFER AGREEMENT AND DISCLOSURE For purposes of this disclosure and agreement the terms "we", "us" and "our" refer to

More information

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Welcome to my office! Below is some information you may wish to read before your first appointment. Included

More information

Giving flight to the Native American Spirit... one family at a time.

Giving flight to the Native American Spirit... one family at a time. Giving flight to the Native American Spirit... one family at a time. The Navajo Brethren In Christ Overcomers serves the San Juan County area through its residential addiction recovery program. We work

More information

Debbie Beach, LCSW Debbiebeach4@gmail.com 202-415-6242

Debbie Beach, LCSW Debbiebeach4@gmail.com 202-415-6242 Debbie Beach, LCSW Debbiebeach4@gmail.com 202-415-6242 COLLABORATIVE ENGAGEMENT AGREEMENT DIVORCE COACH Debbie Beach, LCSW 405 N. Washington St, #104 Falls Church, VA 22046 Date: Name of party: Dear Party:

More information

Brown-Nicollet-Watonwan Adult Drug Court. Participant Handbook

Brown-Nicollet-Watonwan Adult Drug Court. Participant Handbook Brown-Nicollet-Watonwan Adult Drug Court Participant Handbook THIS BOOK BELONGS TO: NAME: CD TX Program: Phone: COUNSELOR: Phone: PROBATION AGENT: Phone: SPONSOR NAME: Phone: SPONSOR NAME: Phone: Do not

More information

HTIC provides specialized equipment when needed. This equipment should only be used for the purpose designed.

HTIC provides specialized equipment when needed. This equipment should only be used for the purpose designed. Board Policies Section: VII.D. Title: Employee Policy Handbook (Staff) Company Policies COMPANY EQUIPMENT HTIC provides specialized equipment when needed. This equipment should only be used for the purpose

More information

Columbia Addictions Center

Columbia Addictions Center Columbia Addictions Center Eileen Dewey, L.C.S.W.-C Director Date: Client Name: Date of Birth: Address: City: State: Zip: Home #: Cell #: E-mail: Preferred contact (circle one): home # cell # e-mail Emergency

More information

CASS COUNTY DWI COURT. Participant Manual

CASS COUNTY DWI COURT. Participant Manual CASS COUNTY DWI COURT Participant Manual 1 I ve been charged with a DWI what happens next? Your attorney will be able to determine if you meet the general eligibility requirements for the DWI Court. Basically,

More information

NORTH CAROLINA ADMINISTRATIVE CODE TITLE ONE - ADMINISTRATION CHAPTER 17 - COUNCIL ON THE STATUS OF WOMEN SECTION.0700 - ABUSER TREATMENT PROGRAMS

NORTH CAROLINA ADMINISTRATIVE CODE TITLE ONE - ADMINISTRATION CHAPTER 17 - COUNCIL ON THE STATUS OF WOMEN SECTION.0700 - ABUSER TREATMENT PROGRAMS 01 NCAC 17.0701 PURPOSE NORTH CAROLINA ADMINISTRATIVE CODE TITLE ONE - ADMINISTRATION CHAPTER 17 - COUNCIL ON THE STATUS OF WOMEN SECTION.0700 - ABUSER TREATMENT PROGRAMS The purpose of the rules in this

More information

Volunteer Application Form

Volunteer Application Form Personal Information Volunteer Application Form Name (First/Last) Phone # Day Evening Cell Email Address How best to contact you? Phone Email Address Street City Postal Code Date of Birth: mm/dd/yr Gender:

More information

PIERCE COUNTY DRUG COURT PARTICIPANT HANDBOOK. Last updated 09.01.13

PIERCE COUNTY DRUG COURT PARTICIPANT HANDBOOK. Last updated 09.01.13 PIERCE COUNTY DRUG COURT PARTICIPANT HANDBOOK 0 WELCOME The Drug Court is an intervention program for adults who have pled guilty to a crime related to their drug or alcohol addiction. It is a cooperative

More information

RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043. PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12)

RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043. PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043 1 PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) Welcome to my practice. This agreement contains important information

More information

What is DOMESTIC VIOLENCE?

What is DOMESTIC VIOLENCE? What is DOMESTIC VIOLENCE? Domestic violence is a pattern of control used by one person to exert power over another. Verbal abuse, threats, physical, and sexual abuse are the methods used to maintain power

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. About this notice

More information

PATHWAY TO RECOVERY RENTAL APPLICATION 1

PATHWAY TO RECOVERY RENTAL APPLICATION 1 PATHWAY TO RECOVERY RENTAL APPLICATION 1 Applicant: Date Driver License # Address Birthdate Social Sec # City State Zip Home Work Co-Applicant: Date Driver License # Address Birthdate Social Sec # City

More information

Employed Full Time Student Part time student Patient s School Name / Employer School/Employer Address City State Zip

Employed Full Time Student Part time student Patient s School Name / Employer School/Employer Address City State Zip PATIENT INFORMATION DATE: Patient s Name Last First Middle Initial Patient s Address City State Zip Patient s Birth Date / / Male Female Age SS# Single Married Other May we call/leave message for appt.

More information

NOTICE OF PRIVACY PRACTICES TEMPLATE. Sections highlighted in yellow are optional sections, depending on if applicable

NOTICE OF PRIVACY PRACTICES TEMPLATE. Sections highlighted in yellow are optional sections, depending on if applicable NOTICE OF PRIVACY PRACTICES TEMPLATE Sections highlighted in yellow are optional sections, depending on if applicable Original Date: ##/##/#### Revised per HIPAA Omnibus Rule ##/##/#### Revised Date Implementation:

More information

STEPHEN CENTER HERO Program ~ Health, Empowerment, Responsibility and Opportunity ~

STEPHEN CENTER HERO Program ~ Health, Empowerment, Responsibility and Opportunity ~ STEPHEN CENTER HERO Program ~ Health, Empowerment, Responsibility and Opportunity ~ The HERO Program is located at 5217 S. 28 th, Omaha Nebraska, 68107. The phone number is (402) 715-5440. The Stephen

More information

White Earth Nation/Becker County Adult DWI Court Program

White Earth Nation/Becker County Adult DWI Court Program White Earth Nation/Becker County Adult DWI Court Program Participant Handbook Name Date TABLE OF CONTENTS Table of Contents... 1 Welcome to the White Earth Nation/Becker County DWI Court... 2 Overview...

More information

Parent s Guide. to Child Protective Services (CPS) Children s. Administration. Division. of Children. and Family. Services

Parent s Guide. to Child Protective Services (CPS) Children s. Administration. Division. of Children. and Family. Services Parent s Guide to Child Protective Services (CPS) Children s Administration Division of Children and Family Services Table Of Contents Topic Page What Is Child Protective Services (CPS)?... What Is Child

More information

We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act ("HIPAA")

We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act (HIPAA) PRIVACY NOTICE We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act ("HIPAA") THIS NOTICE DESCRIBES HOW PERSONAL AND MEDICAL INFORMATION ABOUT YOU MAY

More information

650 Clark Way Palo Alto, CA 94304 650.326.5530

650 Clark Way Palo Alto, CA 94304 650.326.5530 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. (Adopted 4-14-03; revised December 2006) If

More information

Counselors are standing by 24/7 waiting for your free call 1-800-861-1768 thewatershed.com

Counselors are standing by 24/7 waiting for your free call 1-800-861-1768 thewatershed.com Counselors are standing by 24/7 waiting for your free call 1-800-861-1768 thewatershed.com Believe Again in Life. In The future. In Yourself. At The Watershed, our passion is helping addicts and alcoholics

More information