NEW HOPE COUNSELING P.O. BOX 2323 GAINESVILLE, GA (770) FAX (770)

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1 GAINESVILLE, GA FAX (770) HALL DUI COURT All clients with a post trial conviction of driving while under the influence in the State Of Georgia are required to complete a DUI/Risk Reduction School. This school must be completed within 5 months from emollment in the DUI Court Program. A copy of the certificate of completion should be brought to our facility after completion in a prompt manner. Failure to complete this school will result in a sanction through the DUI Court Program. I agree to complete the DUI/Risk Reduction School with documentation of completion provided by which is five months from my first date of treatment. I understand that failure to complete this school and evaluation will result in sanctions through the DUI Court Program. After , all DUI offenders are required to have a Clinical Evaluation in addition to the DUI/Risk Reduction School as a standard condition of probation unless specifically waived by the judge for first offenders. This evaluation may be completed with New Hope Counseling for a fee of $45 or can be completed at another facility of your choice at their fee. However, should it be completed at another facility, the evaluation must be transferred to New Hope Counseling in order to receive credit for its completion. All clients in the Hall County DUI Court Program are required to complete a Clinical Evaluation. This evaluation must be completed within ten months from emollment in the DUI Court Program. Failure to complete this evaluation will result in a sanction through the DUI Court Program. I agree to complete the Evaluation with documentation of completion provided by, which is ten months from my first date of treatment. I understand that failure to complete this evaluation will result in sanctions through the DUI Court Program. Georgia law establishes the Department of Behavioral Health & Developmental Disabilities (DBHDD) rules. The DBHDD Division of Addictive Diseases (DAD), DUI Intervention program (DUIIP) is designated as the agency to implement the provisions of the rules.

2 GAINESVILLE, GA FAX (770) Medication Group: If you are on prescription medications, you may be required to attend the Medication Group at New Hope Counseling. This group is on Mondays at 7:30pm. Failure to attend this group may result in sanctions from the DUI Court. You will need to provide a list of your medications to Nikki Allemani at New Hope Counseling to determine if you will need to attend this group. If you are required to attend the Medication Group and you decide to stop taking your medication, it is important that you discuss this decision with your doctor. You must have written documentation from the prescribing doctor stating that you are no longer taking the medication. This documentation must be received by Nikki Allemani at New Hope Counseling before you are permitted to stop attending the Medication Group. Absences: If you miss a regularly scheduled group or individual session, you are required to attend a make-up session. Missed sessions that require a make-up session include any excused absences or unexcused absences. This also includes missed sessions due to jail sanctions. You must attend a make-up session for every regularly scheduled session that you miss. If you miss group due to DUI School, you must provide documentation that you are attending in order to be excused from attending a make-up session. Make-up sessions are on Saturdays from 8:45am until12:00pm. You must call the main office to schedule your make-up session in advance. Failure to schedule or attend your make-up session may result in sanctions from the DUI Court. Witness The HIPPA Privacy Rules requires covered entities to safeguard certain Protected Health Information (PHI) related to a person's healthcare. Information being sent to you may include PHI, after appropriate consent, acknowledgement, or authorization from the patient or under that circumstances that do not require patient authorization. You, the recipient, are obligated to maintain PHI in a safe and secure manner. You may notre-disclose this patient information without additional patient consent or as required by law. Unauthorized re-disclosure or failure to safeguard PHI could subject us, or you, to penalties described in federal (HIPPA) and state law. If you, the reader of this message, are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, please notify us immediately and destroy the related message. Thanks for your help!

3 GAINESVILLE, GA FAX (770) Please be advised that beginning Monday 04/12/2010, all Hall County DUI Court clients that are prescribed medications will be required to attend weekly group sessions. You will arrive at 322 Spring Street (same location that you currently attend group sessions) at 7:30p.m. for check in. Doors will be locked at 7:45 and clients arriving after this time will not be allowed to enter group. The Medication Group is held every Monday from 8 p.m. to 8:50p.m. Failure to attend this group will result in a sanction through the court. You will be charged an additional $1 0 per week for this group. This charge will be added to your monthly invoice. I have read the above and have been given an opportunity to ask questions. Print Name The HIPPA Privacy Rules requires covered entities to safeguard certain Protected Health Information (PHI) related to a person's healthcare. Information being sent to you may include PHI, after appropriate consent, acknowledgement, or authorization from the patient or under that circumstances that do not require patient authorization. You, the recipient, are obligated to maintain PHI in a safe and secure manner. You may not re-disclose this patient information without additional patient consent or as required by law. Unauthorized re-disclosure or failure to safeguard PHI could subject us, or you, to penalties described in federal (HIPPA) and state law. If you, the reader of this message, are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, please notify us immediately and destroy the related message. Thanks for your help!

4 Northeastern Judicial Circuit DUI Court STATE OF GEORGIA Debbie Mott, Director PO Box 1435 Gainesville, GA Hall County Ph (770) Fax ( AA/NA Sign-in Sheet Acknowledgement I understand that forgery of AA, NA, or other support group sign-in sheets or turning in a support group sign-in sheet with meetings that I did not attend is grounds for immediate expulsion from the DUI Court Program and may result in a probation revocation of the remainder of my sentence. I understand that I am to attend each meeting in full. I am not to arrive late or leave early from a meeting that I am documenting on my form. I understand that the chairperson of the meeting is the only person who is allowed to sign my meeting sheet. If the chairperson of the meeting is a current DUI Court participant, then the co-chairperson is the only person who is allowed to sign my meeting sheet. I understand it is my responsibility to ensure the correct information, i.e., date and time, is completed on my meeting sheet and that all information is filled out in order to receive credit for the meetings attended. I understand that meeting attendance is from Sunday through Saturday before group time. The completed meeting sheets are to be turned in the black box at New Hope on Saturday when I attend group. I understand that if I do not attend meetings as directed, if I tum in AA sheet forms that are incomplete, or if I turn in my meeting sheet late, this may result in sanctions from the DUI Court. I have read the above and agree to follow through with all requirements. (Participant's and )

5 New Hope Counseling P.O. Box 2323, Gainesville, GA Phone 770) Fax 770) Name: : 1 ocation AA/NA: Chairperson: [Topic: : _ I Time: Location AA/NA: I Chairperson: Topic : Time: Location AA/NA: Chairperson: j Topic: j - : ftime: I Location AA/NA: r rperson: I Topic_: t : [Time: Location AA/NA: Chairperson: Topic: I 1

6 Gainesville, GA Fax (770) All DUI Court clients will be billed monthly for treatment fees. Your payments will need to be turned in at 322 Spring St. on the 2nd floor. There is a mailbox to drop your payments in. There will be a file cabinet with a file for each client that will contain your invoice. The procedure will be the same as it is at Treatment Services. On court weeks, payments must be received on Tuesday by 7:30pm in order to receive credit before court. Counselors or other New Hope staff will not accept payments from you unless you are paying with credit card. Credit card payments can be made in the main office only. Main office hours are Monday- Thursday: 9am-5pm, and Friday: 9am-4pm. All payments in the mailbox MUST be paid by MONEY ORDER ONLY (made out to New Hope Counseling) and your name MUST be legible. Print Name The HIPPA Privacy Rules requires covered entities to safeguard certain Protected Health Infonnation (PHI) related to a person's healthcare. Infonnation being sent to you may include PHI, after appropriate consent, acknowledgement, or authorization from the patient or under that circumstances that do not require patient authorization. You, the recipient, are obligated to maintain PHI in a safe and secure manner. You may notre-disclose this patient information without additional patient consent or as required by law. Unauthorized re-disclosure or failure to safeguard PHI could subject us, or you, to penalties described in federal (HIPPA) and state law. If you, the reader of this message, are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, please notify us immediately and destroy the related message. Thanks for your help!