Renaissance Ranch Ogden Full Client Intake Form

Full Renaissance Ranch Ogden Intake Form

1New Client Application

2Treatment Contract

3Non Refundable Policy

4TB Screening

5Insurance Claims Policy

6Consent to Service

7Client Rights

8Follow-Up Services

9Release of Information

10Program Rules & Conduct

11Family Confidentiality Agreement

Full Legal Name*
Address*
Phone*
Date of Birth*
Social Security Number*
Email*
Referred By Agency
Referred By Agency Name
Phone
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
Medical Conditions (including allergies, chronic conditions, communicable diseases)*
Prescription Medications*

Name*
Phone Number
We are wanting to measure the quality of service that we have provided here at Renaissance Ranch to our patients. This particular information is important to help improve the services we offer to you and the recovery community.

This information will be collected within 30 days of you having been discharged or graduating from Renaissance Ranch. We would appreciate your cooperation in improving our services. Your opinion matters to us. You are not required to participate in this survey and can withdraw from this survey at anytime. You will not be denied from receiving further services from Renaissance Ranch R such as After care or returning to the program if you feel the need.

Please be assured we care about your confidentiality, and by participating in this survey it will not be compromised in any way. If you have any questions concerning this survey, please fell free to speak with a staff member.

I give consent to be contacted after graduating or discharging from Renaissance Ranch within 30-days to participate in this followup survey. I know that I do not have to participate if I so choose not to. I also understand that any information I give after being discharged is still protected under the Federal Confidentiality Regulations (42 DFR part 8)

The following notice will Accompany Any Disclosure

This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR part 2)

The Federal rule prohibits you of making any further disclosure of this information unless further disclosure is expressly permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute an alcohol or drug patient.
Signature*

Name*

I agree:

Attend groups on time and be prepared with completed assignments.
Attend 4 meetings a week during IOP (90 days), Clients will complete the required 12 step work before stepping down to GOP (90 days). Client will then attend 2 meetings a week for GOP (90 days). The IOP & GOP groups on-site are included in this plan. We will not count 2 meetings in one day.
There will be attendance of official 12 step meetings. Informal meetings will not be counted unless there are prior arrangements with a counselor.
I will give at least a 4 hour notice to the staff if I am unable to attend groups. This will be considered an excused absence. Anything less than 4 hours of notice, will be considered an unexcused absence. (3) Three missed IOP groups or more that are unexcused absences can result in the dismissal of the participation from the program. (2) Two missed GOP or more unexcused absences in a month can result in a dismissal from the program.
I agree to make up any GOP missed groups by attending another day that I am not scheduled to attend.
Complete treatment work and assignments on time and come prepared to groups with material that is provided.
Wear appropriate attire which included:
Females: No shorts or short skirts. No low cut shirts or shirts that show the mid area. No swim suits or tank tops.
Males: NO tank tops
Comply with reasonable staff instructions.
No Smoking within 25 feet of any entrances to the building or its adjacent entrances. This includes the parking lot.
Not to engage in theft or illegal activity on or off the premises. This will result in immediate dismissal from the program.
DO NOT possess or consume alcohol, drugs or any other mood altering substances. This could result in dismissal from the program.
If you call in sick, you will come to the Renaissance Ranch facility to drug test on that day or bring an actual Doctors note on letterhead from the Dr. office in which you attended.
Clients are able to file a grievance if they feel they have been wronged in any way. Grievances must be in writing and will be addressed in writing with 3-5 business days.
Clients are not to verbally threaten or physically abuse other clients or family members. This type of behavior will result in immediate dismissal from the program.
I am willing and will be responsible cost wise for any outside testing due to urine analysis at the lab, upon request of the counselor or other staff members.
Not borrow any money from another RR client, nor do any business transactions with another client while in treatment. Failure to adhere to his may result in discharge.
Stay active and engaged in the group process, and my own recovery process. This includes openly discussing my recovery issues, making progress towards recovery, as well as giving/receiving feedback.
Not engage in Therapy Interfering Behaviors and be honest about another client's violations.
Not bring Cell Phones in Group Room!!! Please leave them out in the lobby, your car, or in your backpack tured off.
Allow personal belonging to be searched for contraband, weapons, drugs, alcohol, etc.
Not bring guns, blades (longer than two inches), weapons or any contraband on site.
Not make ANY threats of physical violence. Threats will not be tolerated.
Use respectful language. No profanity or vulgarity in public and common areas.
Not date, nor become romatically or sexually involved with another client, or former client, while attending this program. This includes pairing off or "hanging out" with member of the opposite sex. This also includes texting inappropriate messages and pictures. Any violation may result in discharge.
Not to engage in inappropriate physical contact, such as, but not limited to: Massage, head on lap, cuddling, flipping, poking, and touching others inappropriate etc.
No smoking or chewing is allowed inside facility or on facility property. This includes Vaping and E-Cigarettes! Smoking is only allowed in a designated smoking area outside, off campus. Please dispose of cigarette butts appropriately.
Attend at least one 12-step meeting per weekend outside group. These must be official 12-step substance abuse meetings. Informal meetings will not be considered unless prior approval from staff is obtained.
Not associate with anyone, including former clients, who are using alcohol or other addictive, mood altering substances, or any people I have used with.
Not be in any setting where drugs are being used or sold, or where alcohol is the primary consumer product. (bars, night clubs, etc.)
Violations may result in discharge from the program.
Staff reserves the right to discharge the client at any time.

I have read & understand the requirements above & will abide by the rules.
Signature*

Name*

I have a full understanding that I am being permitted to attend family groups at Renaissance Ranch during group hours. In this circumstance, I understand I will see and hear things that are discussed in the utmost confidence of the patients attending this program through Renaissance Ranch. I am therefore agreeing that I am bound by Utah stat law 42- CFR part 8 to not discuss whom I see or what I hear outside the clinic. I agree to keep all patient information confidential.

(Notice: This communication may contain protected health information, the release of which is restricted by federal law. Any information about a client or clients has been disclosed to you from records protected by federal confidentiality rules governing federally-assisted drug or alcohol abuse programs (42 CFR part 2) and the Heath Insurance Portability and Accountability Act of 1996 (HIPAA). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person whom it pertains or as otherwise permitted by 42 CFR part 2, and HIPAA. A general authorization is NOT sufficient for this purpose.)
Signature*
Comments
This field is for validation purposes and should be left unchanged.

Renaissance Ranch Ogden Full Client Intake Form

Full Renaissance Ranch Ogden Intake Form

Client Intake Forms

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Renaissance Ranch Ogden