Intake Form

Recovery Trail

Screening Application for Admission

 

Date Date

 

Full Name Resident first name Resident last name

Current Address Resident mailing address

Phone Number Resident phone

Date of Birth Resident birthdate

Social Security Number Text field

Height/Weight Text field

Email Address Resident email

Emergency Contact Name: Contact 1 name Phone: Contact 1 phone

Type: Contact 1 type Email: Contact 1 email

 

 

What are your primary drugs of choice? Resident substance of choice

When was the last time you used? Resident sobriety date

 

How long have you been using? Text field

 

Can you pass a drug test today? 

Radio buttons

 

Have you ever been to treatment, if so where and when (fill out below):  Treatment Centers

Treatment Center #1

Name: Treatment center 1 name

Started: Treatment center 1 started Ended: Treatment center 1 ended

Notes: Treatment center 1 notes

Treatment Center #2

Name: Treatment center 2 name

Started: Treatment center 2 started Ended: Treatment center 2 ended

Notes: Treatment center 2 notes

Treatment Center #3

Name: Treatment center 3 name

Started: Treatment center 3 started Ended: Treatment center 3 ended

Notes: Treatment center 3 notes

Did you successfully complete treatment?

 Radio buttons

 

 

If you are currently in treatment where, and what is your counselors name? Text field

 

Have you ever been to sober living and or a recovery residence? If so when, and where?_Text field

 

Do you feel like you are person who struggles with substance abuse? Text field

 

Are you currently taking any medications? (List all medications, dosage, frequency, and prescribed by whom) 

Medication

Medication #1

Medication: Medication 1 name Dosage: Medication 1 dosage

Quantity: Medication 1 quantity Category: Medication 1 category

Frequency: Medication 1 frequency MD: Medication 1 md

Notes: Medication 1 notes

Medication #2

Medication: Medication 2 name Dosage: Medication 2 dosage

Quantity: Medication 2 quantity Category: Medication 2 category

Frequency: Medication 2 frequency MD: Medication 2 md

Notes: Medication 2 notes

Medication #3

Medication: Medication 3 name Dosage: Medication 3 dosage

Quantity: Medication 3 quantity Category: Medication 3 category

Frequency: Medication 3 frequency MD: Medication 3 md

Notes: Medication 3 notes

Medication #4

Medication: Medication 4 name Dosage: Medication 4 dosage

Quantity: Medication 4 quantity Category: Medication 4 category

Frequency: Medication 4 frequency MD: Medication 4 md

Notes: Medication 4 notes

Medication #5

Medication: Medication 5 name Dosage: Medication 5 dosage

Quantity: Medication 5 quantity Category: Medication 5 category

Frequency: Medication 5 frequency MD: Medication 5 md

Notes: Medication 5 notes

 

 

Do you feel the medications you are taking are working for you?  Text field

 

Have you ever been diagnosed with any of the following (Check each that apply):

Dropdown

 

Please list all major health issues. Examples are high blood pressures, allergies, diabetes, seizures, etc. 

Paragraph

 

Please share more with me about your diagnosis:

Paragraph

 

Do you agree with these diagnosis? Text field

 

Who is your primary care doctor? Text field

 

Are you currently employed? If not what kind of work have you done in the past?Resident current employment

 

Will you need Recovery Trail to communicate with probation, or a professional practice board?Text field

 

Is your family involved in your recovery? If yes who?

Paragraph

 

How will you handle the financials of being a resident?

Text field

 

Have, or are you receiving county, state, or federal benefits? If So what are you receiving and why? Text field

 

Have you ever been charged or convicted of a crime? Text field

 

Are you currently on probation? Text field

 

If yes please provide the probation office name and phone number: Text field

 

Do you have any pending charges or court dates coming up? If yes please explain in detail:

Paragraph

 

Are you currently completing community service or other tasks to fulfill a ruling?

Paragraph




Why do you want to engage sober living with Recovery Trail?

Paragraph

 

What are the top three things you hope to accomplish while working with our team? 

Paragraph

 

The team at Recovery Trail recognizes that recovery is an individualized journey. We use a person centered approach to create a recovery plan specific to each individual we work with. You will be required to partner with one of our clinical therapists to help create the recovery plan that will give you the best opportunity for successful long term recovery.













Recovery Trail

Resident Rights

 

Recovery Trail does not discriminate based on age, race, sexual orientation or religion. As a resident of the Recovery Trail community you will continue to enjoy all of your fundamental human, civil and constitutional rights.

 

Additional resident rights include, but aren't limited to:

  • The right to be treated with dignity and respect.
  • The right to be informed in writing about services and fees before you enter in to a program agreement with Recovery Trail.
  • The right to confidentiality.
  • The right to manage your own money or to choose someone else you trust to do this for you.
  • The right to keep and use your personal belongings and property as long as it doesn't interfere with the rights, health, or safety of others.
  • The right to be informed about your treatment options, medications, and to see a doctor of your own choice.
  • The right to have a choice over your recovery services and treatment schedule.
  • The right to updates on your treatment process by competent staff members.
  • The right to a home like environment.
  • You have the right to leave Recovery Trail at any time.



I agree with the above information

Name: Resident first name Resident last name

Signature: Signature

Recovery Trail

Internal Policies and Procedures

 

Recovery Trail is (will be) an affiliate of The Tennessee Alliance of Recovery Residences (TN-ARR). We diligently follow the recommendations of TN-ARR and the National Alliance for Recovery Residences (NARR)  in regards to standards of operation and ethics. The following document has been prepared in accordance with the NARR 2.0 Standards adopted with input from SAMHSA and originally ratified by NARR in October 2015.




Operations:

 

Recovery Trail Mission Statement:

Our Mission is to offer an affordable, safe, sober living environment for Sevier county. We will engage our residents in 12-Step based, spiritual, accountable living practices.



Recovery Trail Vision Statement:

Our Vision is to create an environment in Sevier County where any one seeking recovery from substance addiction can find a safe supportive environment in which to do so.



Financials and record keeping

Recovery Trail policies require that fees and charges will be presented and explained to prospective residents prior to entering in to binding agreements.  This includes any potential fees a resident may be responsible for such as lab work or doctor visits if health insurance is not utilized or if insurance claims are denied. We will utilize Quickbooks to document and ensure accurate and complete records of charges, payments and deposits. This also provides the ability to offer residents a history of payments and charges upon request. Recovery Trail will provide this information to residents within 72 hours upon request. Recovery Trail is committed to keeping resident information confidential.  All resident information will be password protected and if in paper form will be “double locked” with access by authorized staff only.

 

The Recovery Trail’s one time admission fee is $200. Program fees are $125 per week. All payments must be via money order, check, direct deposit, or cash. Program fees are due each Friday by 5pm. Residents will be given a grace period until the following Monday at 5pm. if fees have not been paid by the following Monday a $2.00 per day late fee will be administered. Fees will be given to the house manager and a written receipt will be provided. If a resident is behind in fees a copy of a current pay stub or a copy of their current paycheck must be submitted to staff until fees are current.  If a resident is 2 weeks behind in their program fees appropriate action will be taken which can include but is not limited to discharge from Recovery Trail. The resident must disclose payment methods or have a financially responsible party who assumes ownership and responsibility for these fees for the duration of the residents stay. Our focus is to help our residents leave our program as an individual that is self sustaining and with the ability to handle daily financial responsibilities.




Refunds

Recovery Trail will not offer any refunds for residents who leave the program, whether voluntarily, administratively, or early. Recovery Trail  will work with residents to provide accurate prorated refunds to a resident that successfully completes the program. Refunds will be provided within 10 business days from date of departure. Refunds will not be offered to any resident who is discharged for violating any Recovery Trail policies including but not limited to: inappropriate behavior,  failing a urine screen and or drug test, breathalyzer, violating any of Recovery Trail policies and procedures, leaving the program without notice, violence, threats, harassment, or any other reason the Recovery Trail recovery team deems unhealthy, inappropriate or damaging to our community.

 

Members’ money

Recovery Trail staff will not involve themselves in residents financial affairs, including but not limited to lending money to residents, borrowing money from residents, or any transactions involving property or services. Recovery Trail will not employ, contract or enter into a paid work agreement of any kind with any resident.

 

Employing Residents

If Recovery Trail chooses to employ, contract with, or offer paid work to any resident for any reason the following shall apply:

No resident will be forced to enter in to work, employment or contracted services with Recovery Trail.

Residents who accept or decline any offer for work, employment or contracts with Recovery Trail will be not be treated differently from any other resident.

Opportunities for work, employment or contract services with Recovery Trail shall be offered to any and all qualified resident and wages shall be in line with fair market wages and at least meet TN State minimum wage standards.

Any employment, contract, or paid work between Recovery Trail and a resident will be terminated immediately if the arrangement negatively impacts the residents recovery or the recovery and morale of the Recovery Trail community.

Any Recovery Trail resident who is terminated from employment, contract, or paid work with Recovery Trail will not face any recriminations from Recovery Trail.

 

Legal business entity

Recovery Trail is a 501 (c) (3) entity, this paperwork can be presented upon request within 72 hours.

 

Insurance policies are in place and further documentation can be presented upon request within 72 hours.





Staff

Recovery Trail staff will be held to the highest standards in our field and be governed by the applicable policies and procedures of their oversight boards. Staff will follow NARR recommended best practices for conduct and resident protection.

 

Staff members and volunteers will receive a regular six month review from Recovery Trail leadership. Staff members without professional certifications or licensure will be required to be moving towards these designations. Staff members will be required to seek a Tennessee Certified Peer Recovery Specialist certification..  Staff members who already have certifications or licensure will be expected to maintain these designations at a minimum. Recovery Trail will work with staff members on an individual basis to support, improve or add certifications, licensure, and address supervision needs.

 

Recovery Trail will conduct appropriate background checks on all staff and volunteers, which at a minimum will include past criminal history, and sexual violations. Any certifications or licensure will be confirmed with the appropriate oversight body.

 

Admissions

All residents who are admitted to Recovery Trail understand and agree to abide by the policies, procedures, and  standards of Recovery Trail. Residents must be willing to actively participate with their case managers to follow their individualized recovery plan. Residents will disclose any negative behavior or thoughts of negative behavior in an effort to work through difficult situations. Potential residents understand that a screening process will take place to determine if Recovery Trail will be a good fit for their recovery journey and if so to create an individualized recovery plan. Residents will be required to complete a standardized Wellness Recovery Action Plan (WRAP) This recovery plan will evolve during the course of a residents stay and will be utilized to to evaluate Resident Trail processes and resident progress and outcomes. Recovery Trail will use this information for continuous quality improvement.

 

Discharge

When a resident successfully discharges from Recovery Trail, staff will present an exit interview in an effort to gain feedback from the resident which will be utilized for continuous quality improvement. Recovery Trail staff will confirm appropriate contact information at this time to facilitate alumni follow up and encourage alumni participation in future Recovery Trail events.

 

Alumni Contact

Recovery Trail staff will make continuing efforts to contact alumni of the program. This can be done through annual, monthly, or weekly follow up phone calls or emails. Recovery Trail plans to institute a resident and alumni newsletter by the end of 2019 which will be emailed to all current and former residents and their families.

 

I agree with the above information

Name: Resident first name Resident last name

Signature: Signature

 





What to Bring

All bedding, (Twin size sheets, queen in private rooms) and pillows

Toiletries

Prescription medications with refill prescriptions if possible

Two forms of identification if possible

Personal vehicle with driver license, proof of insurance, and registration

Season appropriate clothing

Laundry detergents and laundry basket

Personal spending money

Recreational items, we do have limited storage space but encourage residents  to bring bikes, golf clubs, books and any other appropriate recreational items.

 

What not to Bring

Any controlled substances prescribed or other

No suboxone, subutex or, methadone

Any mood altering substances, including but not limited to  products containing alcohol, specifically mouthwash, and cold medicine

Weapons of any kind

Valuable property that cannot be replaced

 

Working with Residents

Recovery Trail will provide all residents and potential residents an orientation to program specifics including but not limited to: all agreements and contracts, standards associated with being a resident, expectations of residents, resident duties, rules, policies and procedures, and services provided. Recovery Trail structure works best for residents who engage the program for a minimum of 180 days. Any resident wishing to stay beyond 12 months will require permission from the owner/operator of Recovery Trail. Residents are free to leave the program at any time.

 

Residents are expected to be involved and actively participate in their individualized recovery plan and all aspects of the Recovery Trail program. Recovery Trail will work with each individual resident to create a specific person centered plan for that individual which will include but not be limited to 12-Step based recovery and working with a sponsor. Recovery Trail considers recovery to be a person centered lifelong process therefore it is expected that residents work with our Recovery team, their case manager and if applicable their outside clinicians to develop a recovery plan including but not limited to an exit plan and a lifelong plan.

 

Resident Meetings and Grievances

Residents of the Recovery Trail community will be provided contact information for staff members and which staff members are on duty via communication boards in the house. Residents have the right to present any grievance to staff. Residents are encouraged to utilize the weekly meeting time to develop plans for maintaining their living space as well as engaging staff to offer suggestions regarding Recovery Trail operations or feed back on pending admissions. This is also an opportunity to bring up unhealthy situations in the living environment, problems among residents and any maintenance issues. Recovery Trail staff shall retain final decision making in all cases. Should a resident feel a grievance has not been addressed appropriately, a formal grievance must be done so in writing. A formal grievance will be addressed by Recovery Trail leadership within 72 hours. If the resident feels that appropriate action has not been taken by Recovery Trail leadership, residents are welcome to submit their grievance to:

I agree with the above information

Name: Resident first name Resident last name

Signature: Signature

 

TENNESSEE ALLIANCE OF RECOVERY RESIDENCES

PO Box 120114

Nashville, TN 37212-0114

Phone:(615) 500-4434  .  Fax: (615-383-2577)

Email: tnarrtennessee@gmail.com

Website: www.tnarr.org

Resident Property Left Behind

If a resident decides to leave Recovery Trail for any reason it is expected that all personal property be taken with the resident. A resident will have 12 hours to remove any property that is left behind. After 12 hours all property will be donated to appropriate community facilities or become the property of Recovery Trail.

 

Drug Screens

Recovery Trail will utilize breathalyzers and Point of Care (POC) cups to conduct random urine drug screens. These are an important clinical tool to keep residents and our community safe and accountable. Should a resident return a positive drug screen, the resident will have the opportunity to pay a local lab to verify a result if the resident feels the result is incorrect. The resident will pay the lab directly to have this additional testing done and will sign a release prior to additional testing allowing Recovery Trail to receive a copy of the lab results. A failed drug screen is grounds for immediate dismissal.

 

Zero Tolerance Policy

Members of Recovery Trail will be discharged for violating the Zero Tolerance Policy which includes but is not limited to:

 

Violence of any kind

Threats of any kind

Harassment of any kind

Discrimination of any kind

Weapons of any kind

Stealing of any kind

Damaging Recovery Trail property or property of another resident

Using or possessing drugs, alcohol or prohibited substances like kava kava, diet pills or kratom

Abuse of over the counter or prescription medications

Any outside charges (stealing from Walmart for example)

Any actions the Recovery Trail team deems unsafe, unhealthy or inappropriate or damaging to our community

 

Medications

Recovery Trail requires that all medications, dosages, and intake frequency be disclosed prior to a person being accepted as a resident. Residents who have prescription medications will be required to take them as prescribed. Staff will conduct random medication counts. Residents will keep their medications in a secured location known to staff members at all times, if medications are kept in a lock box of any kind, Recovery Trail staff MUST have a spare key. Residents who wish to change medications, start a new medication, stop a current medication or change dosage must work with the Recovery Trail team, their case manager, clinician (if applicable), and consult an appropriate medical professional. Any changes must be documented in writing to staff prior to enacting. Recovery Trail will work with residents that are on a Vivitrol protocol.

 

Curfew

Residents will be awake and ready to start the day by 7:30am. Residents will be expected to be in the residence and accounted for by 10:30pm. All activities are to be quieted by 11pm in respect for other residents. Any absence or tardiness must be approved by staff.  

 

Recovery Meetings and Activities

Members are expected to attend and document a minimum of 6 recovery oriented meetings per week. Appropriate recovery meetings include but are not limited to Alcoholics Anonymous, Narcotics Anonymous, Smart Recovery, Celebrate Recovery, and Refuge Recovery. One House Meeting and one educational/ life skills group per week are to be included in the 6 total for a given week. All weekly meeting sheets must be turned in during the house meeting. Residents will meet with a staff member to determine appropriate recovery meetings outside of those listed. Many staff members of Recovery Trail are people in long term recovery. We recognize the need for a support network outside of the treatment realm. Members will be required to seek a sponsor while living in our community, if you need assistance with this please see your case manager. Recovery Trail will facilitate opportunities for residents and staff to engage each other in informal environments, from the residence itself movie nights, hiking, BBQs, etc. to appropriate recovery oriented activities in the community.  

 

Food

Recovery Trail residents are required to purchase and prepare their own food. Members are welcome to keep food in the residence and any stealing of food will result in discharge. Recovery Trail residents will be required to come together once a week  for a community meal together.

 

Cleaning

Residents will keep their living area clean and organized. Beds must be made daily. Daily and weekly chores will be determined by residents and residents will hold each other accountable for completion of these chores with oversight by staff. The community will elect a “senior” resident each month to lead this process.

Tobacco

Residents are allowed to use tobacco products. ALL tobacco consumption MUST be done in designated areas. There is to be NO tobacco or vape consumption of any kind inside the residence.

 

Neighbors

Recovery Trail residents are expected to be good neighbors. As a Recovery Trail resident you must be courteous to our neighbors. If you have any issues with neighbors communicate this with staff for assistance in addressing these issues. Any situation involving a resident and neighbor should be short and polite. Any problematic or negative interaction between resident and neighbor must be reported to staff immediately.  If the neighbor is seeking any information outside of daily pleasantries the resident will immediately get a staff member or provide a phone number for a staff member and end the encounter.

 

Safety, Information and Communication

A communication board will be in a conspicuous location listing all Recovery Trail resident paperwork and important safety phone numbers, fire, police, on-duty staff members, etc. Evacuation maps will be placed conspicuously on each floor of the residence in case an evacuation is necessary. Recovery Trail staff will determine a safe location for all staff and residents to congregate should an evacuation of the property be necessary. If an evacuation does occur, all staff and residents will meet at the designated spot, staff will conduct a count to make sure all staff and residents are accounted for. Recovery Trail will reiterate this plan at least once a month during our weekly house meeting.

Recovery Trail will conduct and keep a record of quarterly tests and inspections of all safety equipment including but not limited to smoke detectors and fire extinguishers. Any resident found tampering with any safety equipment for any reason can face immediate dismissal. Recovery Trail will keep Narcan kits available in the residence. Recovery Trail will regularly train staff and residents on administering Narcan should the need arise.

 

I agree with the above information

Name: Resident first name Resident last name

Signature: Signature

Recovery Trail

Release of information



This form, when completed and signed by you, authorizes Recovery Trail to release, request, or exchange any or all protected health information from your medical, clinical, or case management records to the person or agency you specifically designate.

 

Section A - Resident Information

Date:Date

 

Name:Resident first name Resident last name

 

Address:Resident mailing address

 

Contact number:Resident phone

 

Birth Date:Resident birthdate



Section B - Information to be Released

I authorize Recovery Trail to release, request, or exchange the following information:

*Please initial where applicable

  1. Contact/Consultation (via Phone, Email, Letter) Text field
  2. Psychological Exam and/or Test Results Text field
  3. Psychotherapy Notes Text field
  4. Medical Records Text field
  5. PHI Only Text field

PHI only - Personal health information, (PHI) also referred to as protected health information, generally refers to demographic information, medical history, test and lab results, insurance information and other data that is collected by health care professional to identify an individual and determine appropriate care.

  1. Staffing Text field
  2. Treatment Summary Text field
  3. Financial Information/BillingText field
  4. Appointment Scheduling Text field
  5. Continuum of Care Text field
  6. Financial information Text field
  7. Other: Please describe specifically Paragraph



Section C - Recipient Information

This information should only be released or exchanged to or with:

*(One Person OR Organization Per Form)

Name of Person/Party/Agency:Contact 4 name

 

Identifier/Relation to You:Contact 4 type

 

Address:Text field

 

Email:Contact 4 email

 

Contact number:Contact 4 phone

 

Section D - Initials and Signature

By default, this authorization shall remain in effect for 1 year from the date signed.

If you would like this authorization to expire SOONER than ONE (1) year from today, please specify here:Date

Date of Authorization expiration:Date

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Recovery Trail. I also understand that my revocation will not be effective to the extent that Recovery Trail has taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

Print full name:Resident first name Resident middle name Resident last name

Date:Date

Signature:Signature

This signature confirms all information provided in Sections A, B, C, & D of this Authorization to Release Information.

Witness:Signature

 

Credit Card on File Agreement

As an authorized signer on the credit card listed below, I give Recovery Trail permission to utilize the credit card for all charges related to and including services rendered at Recovery Trail.

Visa/MC Account Number:Text field

Expiration Date: Text field

Security Code or CID #:Text field

Billing Zip Code: Text field

Name on Card: Text field

Name of Client(s):Text field

Phone Number: Text field

Email address: Text field

Signature: Signature

Date:Date