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Intake information for website 2_09
After either a referral by a recognized organization or contact via telephone or walk-in, the client will be placed on the waiting list. While on waiting list client wil participate in a screening process: an initial interview with a staff member to confirm criteria for entry and suitability. This is done either over the phone or in person. If individual is eligible, she will have to have these items before entering treatment (unless there is an asterisk): WHAT TO BRING ON-SITE (If client does not have items, it could cause an individual to not be received into intake on the day of original appointment for personal screening/assessment. This could cause an individ-ual to actually loose a bed). ROS is not responsible.
Proof of Income (W-2, Food Stamp, Letter of declaration by someone else notarized) MANDATORY Picture ID or License Social Security Card Food Stamp Card*If individual does not have one, we will help process. Also, If client has food stamp
card and comes without children but has children on the card, client must go to Food Stamp office and get children off the card.
List of disclosure of debt, such as courts, bad checks, child support, outstanding bills
Medicaid or Medicare card Or a clearance letter at Medicaid office *not mandatory 2 letters of reference Background clearance – *In extreme circumstances, the client is approved to move on site before the
background check is finished. Then if background check is not clear, client will have to move off site.
If coming from OCS a clear letter of boundaries Name, location, and phone number related to case workers If coming from a probation officer, judge, parole officer a clear letter of boundaries Name of probation/parole officer or judge, phone number and fax number If you are going to need housing or bring children – need Social Security card of all children, birth cer-
tificates of self and children and a LA ID
Restraining order either against someone or against “you” Disclosure of Medication *No medication is allowed that is listed on our following list Verification of conditions (if applicable), verifications of al ergies, restrictions (dated, Doctor’s name, dosage, or
samples with prescription– doctor, not immediate family)
Medical records or verification if physical y restricted; such as diabetes, hepatitis, (and what), bad back… (if you
do not come with verification, any medication related wil not be acceptable)
Disclosure of mental health involvement: last appointment, contact name TB Test *not mandatory
If client is entering residential treatment, •
This is an 18 month program. The client must be prepared to stay on site for a minimum of six months, then transition off-site will be based in assessment progress and assessment of risk factors. The remainder is after-care, which is mandatory. The after-care schedule is based in personal assessments/progress.
The client may not have access to personal transportation until both client and staff agree (1 year).
The client may not have access to personal finances until both client and staff agree (earliest is nine months—see money section).
Clients may not have any music devise, such as radio, ipod, or the like.
Clients may not bring personal computer.
Clients may only wear one earring in each ear, and wear no other body piercing jewelry. Then client can only wear an earring stud (no hoops or dangling). One ring on one hand. Any other jewelry is a privilege and can be earned (but never any more jewelry in body piercings except single in each ear). *see jewelry container size. Before it is earned, container is locked in staff closet. (Advise is to not bring any until privi-
Clients may not bring any personal pillows, blankets, comforters, towels… (unless documented by a doctor)
The client must agree to follow ROS Continuing Care Program.
The client, unless married or in a long-term relationship (meaning a committed, healthy, faithful, [no abuse or using-together history, validated by at least two objective healthy blood kin or individuals] monogamous relationship of at least 1 year… exceptions rare), must agree not to develop a relationship with anyone, nor engage in any sexual relationships while in the residential program (residential primary care, transitional living). Staff qualifies these relationships. Just because you are married or a partner is the father of your child, if the person is actively using, history of abuse or using within a year, does not mean the person is cleared. Many steps will be taken before even considered. This will be reassessed after every three months.
CLIENT MAY BRING ON SITE (boundary of items included…)
*ROS will not be responsible for important papers
IF Camera. is turned into staff in locked box. Only allowed on
weekends. ROS not responsible for loss or damage.
NOTE: DO NOT BRING ANY BOOKS except what is
OTHER ITEMS CLIENTS MAY BRING ON SITE •
Alarm clock (not clock radio), hair dryer
Writing equipment, Bible (not a Recovery or Commentary), and Big Book if available
NO MORE THAN 8 PAIR OF SHOES, including a pair of tennis shoes. No heel shoe is worn to class. No more than a 2” heel is allowed for business casual outings or church.
Prescriptions such as, but not limited to:
Any over the counter medication containing
Ephedra, Ephedrine (or any other dietary Supplements)
No OTC sleep aides, NO OTC medication (w/out proper clearance), no vitamins, no health food supplements, no herbal dietary products, no energy drinks, no diet pills, or the like.
*Exceptions are very rare and must be cleared with ROS executive staff and designated doctor. Any further questions, please call the office at 318.323.0502 or email. We look forward to serving you.
Peninsula-Delaware Conference of the United Methodist Church 1 Day Service Project 2014 MEDICAL RECORD AND LIABILITY RELEASE FORM (Each person must bring this form with them in order to register. Persons without a form will not be able to attend.) Date of conference: April 5, 2014 Church: _________________________________________ Date signed: _______________ SECTION 1: MEDICAL
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