DWI Short Term Intake Packet

S&H Youth and Adult Services, Inc.

Name*

First NameLast Name

Date of Birth*

Date

Date*

Date

Driver License/ID#*

Own GuardianLegal Guardian

Name: (first middle last)*

Insurance or Medicaid ID #

License Number #*

Admission Date*

Date

MaleFemale

Date of Birth*

Date

Soc. Sec. #*

Current Address: (Street, City, State, Zip Code)

Current Address*

Telephone Number*

Format: (000) 000-0000.

Eye Color*

Hair Color*

Height*

Weight

Highest Grade Completed *

Guardian Name Address & Phone

Format: (000) 000-0000.

Allergies/Medical Alerts*

Emergency Contact Name*

Emergenty Contact Relationship*

Emergency Contact Home/Cell phone number*

Format: (000) 000-0000.

Emergency Contact Address: (Street, City, State, Zip Code)

Emergency Contact Work phone number

Format: (000) 000-0000.

Emergency Contact 2 Name

Emergency Contact 2 Relationship

Emergency Contact 2 Home phone number

Format: (000) 000-0000.

Emergency Contact 2 Address: (Street, City, State, Zip Code)

Emergency Contact 2 Work phone number

Format: (000) 000-0000.

S&H Youth and Adult Services, Inc.

Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD)

During the past 6 months:

YESNO

Blackouts or other periods of memory loss?Injury to your head after drinking or using drugs?Convulsions or delirium tremens (DTs)?Hepatitis or other liver problems?Felt sick, shaky, or depressed when you stopped drinking or using drugs?Felt "coke bugs" or a crawling feeling under the skin after you stopped using drugs?Injury after drinking or using?Used needles to shoot drugs?

NOYES

YESNO

Client's Signature*

Date*

Date

S&H Youth and Adult Services, Inc.

Scoring for the Simple Screening Instrument for Substance Abuse

Simple Screening Instrument for Alcohol and Other Drugs (SSI-AOD) Score Sheet

Items 1 and 15 are not scored.

The following items are scored as 1 for each yes answer and 0 for each no answer.

Client's Signature*

Date*

Date

Score Degree of Risk for Substance Abuse

4 or more Moderate to high: possible need for further assessment

Questions 1 and 15 are not scored, because affirmative responses to these questions may provide important background information about the respondent but are too general for use in scoring.

The observational items are also not intended to be scored, but the presence of most of these signs and symptoms may indicate a substance abuse problem. It is expected that people with a substance abuse problem will probably score 4 or more on the screening instrument.

A score of less than 4, however, does not necessarily indicate the absence of a substance abuse problem. A low score may reflect a high degree of denial or lack of truthfulness in the subject's responses. The scoring rules have not yet been validated, and thus the substance abuse screening instrument needs to be used in conjunction with other established screening tools when making referrals.

Referral Issues The substance abuse screening instrument, as a first step in the process of assessment for substance abuse problems, can help service providers determine whether an individual should be referred for a more thorough assessment. When an individual with a potential substance abuse problem is identified through the instrument, the interviewer has the further responsibility of linking the individual to resources for further assessment and

S&H Youth and Adult Services, Inc.

AATC of SHYAS - Assessment Summary

ADETS Minimum Service RequiredNo diagnosis or only partial criteria are met, defensiveness, guardedNo statutory/administrative rule exclusions

Mild substance use disorder: 2-3 Symptoms and/or any of the following:Prior Convictions,Refusal,BAC . 15 or more

Mild substance use disorder: 2-3 Symptoms and/or any of the following:

Substance Use Disorder, Mild, Early or Sustained remission

Short or longer term Minimum Service RequiredModerate substance use disorder: 4-5 symptoms:Substance Use Disorder, Moderate, Early or Sustained remission:Substance use disorder, Severe, Sustained remission

Moderate substance use disorder: 4-5 symptoms:

Longer term or higher level (IOP) Minimum Service Required

Substance Use Disorder, Moderate, Early or Sustained remission:

Severe substance use disorder: 6 or more symptoms:

Severe substance use disorder: 6 or more symptoms:Substance Use Disorder, Severe, Early remission:

Substance Use Disorder, Severe, Early remission:

Signature indicates I understand that I must provide SHYAS the documentation needed for the 508 completion form.*

assessment is no longer valid. The DMV requires that you once again pay the standard fee for a new

I understand the above summary. I recognize that compliance with the recommended Treatment program is my responsibility. Noncompliance will result in the DMV permanently withholding my driver's license.

Client signature & Date*

S&H Youth and Adult Services, Inc.

Client Rights / Grievances Document

Client Rights: I understand my basic rights as a client. These rights include but are not limited to dignity, privacy, humane care and freedom from abuse, neglect, exploitation and mistreatment in accordance with applicable standards set forth in Area Program Standards Manual (APSM) 95-2. The rights of have been explained in both written and oral form at the time service to ensure understanding of written

Grievance Policy: I understand that if I have a complaint/grievance, I should: When persons expresses a formal complaint to S&H Youth and Adult Services, Inc representatives will listen and if appropriate resolve any immediate issues within the scope of their specific job duties or encourage the person to contact the next appropriate S&H Youth and Adult Services, Inc representative or Director to seek resolution. Using these procedures, the S&H Youth and Adult Services, Inc representative will document and investigate the concern. 1.Inform the person the concern has been received and is being reviewed. 2.Discuss the concern with the person and if appropriate, the employee. 3.Identify the possible causes of the concern. 4.Plan and implement an appropriate course of action. 5.Follow up to determine if the concern has been alleviated. 6.Inform the person of the action taken. 7. A concern could become a grievance, and a grievance requires further investigation as well as a response from the agency. To be processedaccording to the S&H Youth and Adult Services, Inc grievance procedure, alleged abuse, neglect, or exploitation must have occurred while the individual was receiving services through S&H Youth and Adult Services, Inc. A grievance may be submitted verbally or in writing, and the individual(s) filing the grievance will be given a copy of the S&H Youth and Adult Services, Inc grievance procedure at the time of filing. Upon Receipt of a grievance: 1. If an alleged violation of an individuals rights (including but not limited to, abuse, neglect, or exploitation) is reported the Director and QM Representative will be notified immediately by the supervisor receiving the report. Please allow 24 hours to process complaint. Convened by the QM Representative, the Internal Risk Assessment (IRA) process will occur within 72 hours. The aggrieved or a representative will present the grievance to the IRA committee. QM/Committee members will review the facts, ask questions and formulate recommendations. These recommendations will be sent to the CEO for review and signature. Upon receipt of a signed IRA document from the CEO (within 48 hours)*. the individual(s filing the grievance will be informed of the approved recommendation by the Director or the designee within 24 hours. *should the CEO conclude that additional information is needed, the IRA committee will re-convene and will have an additional 5 day period to gather information, submit to CEO for review and be informed of the approved recommendations. 2.A grievance that does not involve the alleged violation of another individual's rights will be submitted to the Director and QM Representative for review. A response will be provided within 7 working days. Should it be determined that additional information is needed, the final response will be made within 5 working days from the date of receipt of the request for additional information. If the issue cannot be resolved through the efforts of the Director and the QM Representative the HRC will review the grievance and attempt to resolve the issue. If necessary, the grievance will be sent to the CEO, whose decision is final.

I understand that I have a right to contact the agencies below at any time to discuss my complaint/grievance:

P.O. Box 10126 Raleigh, NC 27605

NC Mental Health/Developmental Disabilities/Substance Abuse Services Shenita Billups shenita.billups@dhhs.nc.gov

Fax: 919-508-0963 North Carolina Substance Abuse Professional Practice Board

http://www.disabilityrightsnc.org/

3724 National Drive, Suite 100

content/uploads/2012/11/complaints.pdf Raleigh, NC 27612

3008 Mail Service Center Raleigh, NC

Katie Gilmore, Associate Executive Director (877)235-4210 or (919) 856-2195

I certify that I have received a copy of this Client Rights/Grievance Policy

Client's Signature*

Date*

Date

S&H Youth and Adult Services, Inc.

Requirements for reinstatement of your driver's license: To have your license reinstated, you must obtain a certificate of completion. A certificate of completion can be obtained by: a) Completing a substance abuse assessment at an authorized NC DWI Services provider and b Completing the recommended leveloftreatmentoreducation atan authorizedNC DWIServices provider.

I understand that I have the right to choose to complete my recommended level of treatment or education at

any authorized NC DWI Services provider. Here is a list of authorized NC DWI Services provider is this area from which I may choose to complete my recommended level of care:

Salisbury, NC 28145 Phone: 704-639-9889

Genesis A New Beginning Rowan 629 W. Innes Street, Suite 214

Salisbury, NC 28144 Phone: 704-636-0838

Sims Consulting and Clinical Services

204 E. Innes Street, Suite 280

I understand that if I have not begun the recommended substance abuse education or treatment to resolvemy DWI within 6 months from the assessment date a new assessment and assessment fee will be required.

I voluntarily choose this AATC of SHYAS to provide my DWI Substance Abuse Assessment.I hereby confirm that Ihave/lhave not already had a Substance Abuse Assessment completed by anyAssessment completed by

Service Level Recommendations:

Signature*

Level: ADETS Minimum # of hours: 16 Duration (Minimum # of days): 5 - You may not miss any days once you have begun class or you will have to start over. Your fee for service must be paid in full prior to the start of class. Additional requirements (i.e., UDS, BAC):NCDMVR, Citation, BAC, No Diagnosis, No missed days of class, Negative UDS, On time for class. Late comers will not be permitted in the classroom and you will have to start the entire 16-hour program over.

S&H Youth and Adult Services, Inc.

Service Level Recommendations continued:

Duration (Minimum # of days) 30 - You may not miss hour program over. Your fee for service must be paid in full prior to the end of class & submission of your treatment 508.

Level: Short Term Treatment Minimum # of hours:

more than 2 consecutive days once you have begun class or you will have to start the entire

Additional requirements (i.e., UDS, BAC): NCDMVR, Citation, BAC, Negative UDS, On time for class. Participants

arriving more than 15 minutes late for group will not be permitted into the group. 2 consecutive absences and/or 4 total unexcused absences will require you to restart your entire short-term treatment program over.

I understand that the following is required to be completed to clear my license.

Level: Long Term Treatment Minimum # of hours: more than 2 consecutive days once you have begun class or you will have to start the entire over. Your fee for service must be paid in full prior to the end of class & submission of your treatment 508.

Duration (Minimum # of days): 60 - You may not miss hour program

Additional requirements (i.e., UDS, BAC): NCDMVR, Citation, BAC, Negative UDS, On time for class. Participants

arriving more than 15 minutes late for group will not be permitted into the group. 2 consecutive absences and/or 4 total unexcused absences will require you to restart your entire long-term treatment program over.

I understand that the following is required to be completed to clear my license.

Level: Intensive Outpatient Treatment Minimum # of hours: 90 Duration (Minimum # of days): 90 - You may not

miss more than 2 consecutive days per month once you have begun class or you will have to restart the entire

90 hour program over. Your fee for service must be paid in full prior to the end of class & submission of your

treatment 508. Additional requirements (i.e., UDS, BAC): NCDMVR, Citation, BAC, Negative UDS, On time for

class. Participants arriving more than 15 minutes late for group will not be permitted into the group. 2

consecutive absences and/or 5 total unexcused absences will require you to restart your entire IOP treatment

I understand that a complete driving history from NC DMV is required for the assessment; I may bring one in obtain it from this facility at the cost I would have incurred if I obtained it myself online at www.ncdot.gov/dmv/online/records/.Assessment Policy: To conduct a substance abuse assessment, the Alcohol Addiction Treatment center of S&H Youth and Adult Services, Inc. shall give a client a standardized test by the Department to determine chemical dependency and shall conduct a clinical interview with the Based on the assessment, Alcohol and Addiction Treatment center of S&H Youth and Adult Services, Inc. recommend that the client either attend an alcohol and drug education traffic (ADET) school or obtain treatment. A recommendation shall be reviewed and signed by a certified alcoholism, drug abuse, or substance counselor, as defined by the Commission, a Certified Substance Abuse Counselor, or by a physician certified American Society of Addiction Medicine (ASAM). The following documents are needed to conduct an assessment: Approved standardized test, Original Citation, Consent to release and exchange information, the driving record, Official BAC, Contract, Clinical Interview, E508, Copy of UDS. Upon completion of assessment the following documents are needed to transfer a consumer regardless of the level of care: A DMH Form and documentation of the driving record, alcohol concentration and the DSM diagnosis shall accompany all referrals regardless of the level of service. All persons assessed shall be provided written documentation that states a DWI assessment is only good for six months. It shall also explain the requirements for reinstatement of the driver's license, including minimum hours and duration of service. If a level of treatment is this written documentation shall be in the form of a client contract that minimally addresses program requirements and fees. Client contract also states that clients receive a base line drug screens as part of the initial assessments will be conducted at no cost and each additional test/drug screens and/or breathalyzers taken throughout my treatment program will be conducted in house at a cost of $15.00 per test. All presumptive positive drug screens will be sent to an outside reference laboratory at an additional cost of $50.00per test.*

I understand that a complete driving history from NC DMV is required for the assessment; I may bring one in

or obtain it from this facility at the cost I would have incurred if I obtained it myself online at www.ncdot.gov/dmv/online/records/.Assessment Policy: To conduct a substance abuse assessment, the Alcohol and Addiction Treatment center of S&H Youth and Adult Services, Inc. shall give a client a standardized test approved by the Department to determine chemical dependency and shall conduct a clinical interview with the client. Based on the assessment, Alcohol and Addiction Treatment center of S&H Youth and Adult Services, Inc. shall recommend that the client either attend an alcohol and drug education traffic (ADET) school or obtain treatment. A recommendation shall be reviewed and signed by a certified alcoholism, drug abuse, or substance abuse counselor, as defined by the Commission, a Certified Substance Abuse Counselor, or by a physician certified

by the American Society of Addiction Medicine (ASAM The following documents are needed to conduct an

assessment: Approved standardized test, Original Citation, Consent to release and exchange information, the

complete driving record, Official BAC, Contract, Clinical Interview, E508, Copy of UDS. Upon completion of

assessment the following documents are needed to transfer a consumer regardless of the level of care: A DMH

508-R Form and documentation of the driving record, alcohol concentration and the DSM diagnosis shall

accompany all referrals regardless of the level of service. All persons assessed shall be provided written

documentation that states a DWI assessment is only good for six months. It shall also explain the requirements for reinstatement of the driver's license, including minimum hours and duration of service. If a level of treatment is required, this written documentation shall be in the form of a client contract that minimally addresses program requirements and fees. Client contract also states that clients receive a base line drug screens as part of the initial DWI assessments will be conducted at no cost and each additional test/drug screens and/or breathalyzers randomly taken throughout my treatment program will be conducted in-house at a cost of $15.00 per test. All presumptive positive drug screens will be sent to an outside reference laboratory at an additional cost of $50.00per test.

S&H Youth and Adult Services, Inc.

Program Requirements and Fees:

I understand that if I complete the recommended level of care at AATC of SHYAS, these will be the program

As a condition of this contract / acknowledge the following items and agree to them.

a.I understand that the cost of the DWI Substance Abuse Assessment will be $100.

b.I understand that it is my responsibility to obtain a copy of the DWI citation that was issued, a copy of the

Blood Alcohol Concentration, and a copy of my DMV driving history prior to my DWI Substance Abuse

Following my assessment I will be referred to one or more services based on the assessment outcome, the diagnosis, and the level of care required. d.I understand that upon my referral to an education or treatment program I have the right to choose a provider of those services. AATC of S&H Youth and Adult Services, Inc. has provided a listing of services that are available locally that also include the NC DWI Services web page

[http://www.ncdhhs.gov/mhddsas/dwi/index.htm)

Iunderstand that the following services are available to me at this facility. 1.DWI substance abuse assessment/Clinical Assessment

3.Short-term Outpatient Treatment 4. Longer - term Outpatient Treatment 5.Intensive Outpatient Treatment 6.Individual Therapy 7. Other: f.I understand that my DWI substance abuse assessment is valid for 6 months. If I have not begun the recommended DWI treatment or education within 6 months from the assessment date a new assessment and assessment fee will be required.

I understand that I will receive a base line drug screens as part of the initial DWI assessment. This test will

be conducted at no cost to me.

h. I understand that I will receive drug screens and/or breathalyzers randomly throughout my treatment program. This testing will be conducted in-house at a cost of $15.00 per test. All presumptive positive drug screens will be sent to an outside reference laboratory at an additional cost of $50.00 per test. I understand that my treatment program requires abstinence from alcohol and drugs for duration of the treatment program. To successfully complete my treatment program I must be alcohol and drug free. I j.understand that if I am not able to maintain abstinence from alcohol or drugs I will notify my counselor and discuss treatment modification options. I understand that treatment will consist of individual and/or group sessions. I understand that these sessions cannot be rescheduled and regular attendance is required. I will notify the counselor in advance if I am going to miss a treatment session. I understand that all missed treatment sessions must be made- up at an additional cost to me. I understand that I must attend the treatment sessions on a weekly basis and within the required timeframe, or I will have to re-start my treatment program.

m.I understand that if I am more than 15 minutes late for a group session, that session will not count

towards the treatment/group session required.

n.I understand that all education/treatment programs are absolutely voluntary. If I decide to terminate

education/treatment I will discuss this decision with the staff.

o.I understand that lack of cooperation by a client may interfere substantially with the program's ability to

render services effectively to the client or to others. If such circumstances should occur the education/treatment program may discontinue services to the client. p. I understand that no weapons, alcohol or drugs are allowed on this property. If these items are discovered it is grounds for immediate termination from all services.

q.I understand that threats of violence or violent acts toward others will be grounds for immediate termination from all services.

S&H Youth and Adult Services, Inc.

I understand that if there is reasonable suspicion that I am under the influence of alcohol or drugs I will be asked to leave the facility. I also understand that if I then attempt to drive from this facility law

I understand that I must pay all education/treatment fees before my DWI Certificate of Completion can be completed. I understand that this agreement covers the length of time I am involved in assessment or treatment activities at this facility and shall not exceed 12 months.

Inclement Weather Policy: AATC of S&H Youth and Adult Services, Inc. does not close at the first sign or threat of snow or ice. The facility does not follow the Local Government/Courts or school schedule. A decision will be once conditions warrant such. There will be a voicemail message on AATC of S&H Youth and Adult Services, Inc. Voicemail (704-603-8285), crisis phone (704-603-8285) if the agency opts to close. If you have any concerns or Questions, feel free to call. Closing is also listed on the website. In the event of Ice, there is a possibility of power outages and power surges in which case the phone System may shut down or revert back to default. Leave a message and use your best Judgment. Generally, if the agency is open, you will be able to reach someone by phone.

Program Requirements and Fees: The Following are the treatment fees of AATC of S&H Youth and Adult Services, Inc. are for those attending treatment for a substance use disorder. A minimum payment of $75.00 is also required by statute for all services. AATC of S&H Youth and Adult Services, Inc. charges $17.50 per hour for treatment. If the cost of treatment is paid in full prior to the start of treatment persons participating in treatment will be charged the following.

$600 for each 40 hour treatment - longer tern treatment

$700 for each 50 hour treatment - longer tern treatment

$800 for each 60 hour treatment - longer term treatment

$1000 for each 90 hour treatment - IOP (intensive outpatient)

Each additional hour is at $17.50

A person who chooses AATC of S&H Youth and Adult Services, Inc. for the provision of treatment services to obtain a certificate of completion may be subject to additional fees $40 for each long term, short term, IOP treatment intake if the assessment was complete by another agency and not AATC of SHYAS. $15 for each urine drug screen $50 for each urine drug screen confirmation

A person who chooses AATC of S&H Youth and Adult Services, Inc. for the provision of ADETS to obtain a certificate of completion is not subject to additional fees. AATC of S&H Youth and Adult Services, Inc. may only charge a person who choses AATC of S&H Youth and Adult Services, Inc. for the provision of ADETS to obtain a certificate of completion a fee of one hundred sixty dollars ($160.00

I voluntarily choose this facility to provide my DWI Substance Abuse Assessment.

I voluntarily choose this facility to provide my education/treatment services per the assessment

I understand that the provider has two weeks to submit the E508 after completion of services and payment.

S&H Youth and Adult Services, Inc.

If you are pre-trial at time of assessment, you MUST inform your Treatment Provider of your conviction date in

order to submit the E508 to the state.

I will contact AATC of SHYAS, the Treatment Provider with questions regarding the status of my E508.

I certify that I have read, understand, and have received a copy of this Service Agreement

Signed in acknowledgement at time of assessment:

Client's Signature*

Date*

Date

Signed in acknowledgement at time of enrollment into education/treatment

Client's Signature*

Date*

Date

S&H Youth and Adult Services, Inc.

CONSENT TO RELEASE & EXCHANGE INFORMATION FOR EMERGENCY ONLY

, hereby authorize AATC of S&H Youth and Adult Services, Inc. to release

or receive specified information from my record for identifying and emergency information only:

Person/Agency releasing or receiving information

Emergency Contact Name*

Relationship to Client*

Emergency Contact Address*

Address

Street Address Line 2

State

Zip Code

Emergency contact Phone #*

Format: (000) 000-0000.

Emergency Contact Fax #

Emergency Contact Phone #

Format: (000) 000-0000.

This information shall include: identifying & emergency information only.

I understand the information will be used for: emergency purposes only.

I understand that this information will only be used in compliance with G.S. 20-17(m), 1987 Chapter 797, Senate Bill 508, as amended. I understand that verification of my compliance with the assessment, treatment, or education called for is necessary for my driver's license to be reinstated, and to comply with a court judgment, if so ordered by the presiding judge. In addition, this information is reported for the purpose of tracking, DWI intervention, and compliance. I understand that AATC of S&H Youth and Adult Services, Inc. may not condition my treatment on whether I sign a consent form. I understand that my records are protected under 45 CFR, 42CFR Part 2, N.C General Statutes and Administrative Codes governing Confidentiality of Alcohol and Drug Abuse Patient Records and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I hereby acknowledge that this consent is truly voluntary and is valid from(not to exceed one year

REDISCLOSURE: Once information is disclosed pursuant to this signed authorization, I understand that the Federal Health Privacy Law (45CFR Part 164) protecting health information may-not apply to the recipient on the information and, therefore may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit redisclosure. When this agency disclosed mental health and developmental disabilities information protected by state law (NCGS 122C) or substance abuse treatment information protected by federal law (42CRF Part 2), we must inform the recipient of the information that redisclosure is prohibited except as permitted or required by these two laws. Our Notice of Privacy Practices describes the circumstances where disclosure is permitted or required by these laws.

REVOCATION AND EXPIRATION: I understand that, with certain exceptions, I have the right to revoke this authorization at any time. If I revoke this authorization, I must do so in writing. The procedure for how I may revoke this authorization, as well as the exceptions to my right to revoke, are explained in AATC of S&H Youth and Adult Services, Inc. Notice of Privacy Practices, a copy of which has been provided to me. If not revoked earlier, this authorization expires upon:Not to exceed one year from date of signature unless for reasons pertaining to 10A NCAC 26B.0202 (b) (1) and (b) (2

OF VOLUNTARY AUTHORIZATION: I understand that I may refuse to sign this authorization form. If I choose not

tosign this form, I understand that AATC of S&H Youth and Adult Services, Inc. cannot deny or refuse to provide treatment,

payment, enrollment in a health plan, or eligibility for benefits on my refusal to sign unless the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party on provision of an authorization for the disclosure of the protected health information to such third party.

Client Signature*

S&H Youth and Adult Services, Inc.

[Patient's Name]*

[Name or general designation of individual or entity making the disclosure]

NC Department of Community Corrections (PO):

NC DMVNC Division of MH/DD/SAS

NC Department of Community Corrections (PO):

[Name of the Criminal Defense Attorney]

[Name of the prosecuting District Attorney]

/ Other ]

[Name of the appropriate court]

my diagnosis, urinalysis results, information about my attendance or lack of attendance at treatment sessions, my cooperation with the

[describe how much/what kind of information may be disclosed, including & explicit description of what substance use disorder information may be disclosed; as limited as possible]

[describe the purpose of the disclosure; as specific as possible]

I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:

[describe date/event/condition upon which consent will expire; must be no longer than reasonably necessary to serve the purpose of this consent]

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. | will not be denied services if | refuse to consent to a disclosure for other purposes. I have been provided a copy of this form.

Client Signature*

Witness/Staff Signature Notice Prohibiting re-disclosure of Substance Use Disorder Information: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part2 The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see $2.31 The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at $2.12(c5) and §2.65.

S&H Youth and Adult Services, Inc.

ROWAN COUNTY DWI PROVIDERS ASSOCIATION

By my signature below, I voluntarily authorize and request AATC of S&H Youth and Adult Services, Inc. to release and exchange information specified below (including paper, oral, and facsimile interchange) with the following parties:

North Carolina Department of Human Resources (State DWI Offices)

North Carolina Division of Motor Vehicles

North Carolina Department of Correction (Probation/Parole)

Licensed DWI Service Facilities in all states / jurisdictions Licensed Treatment Facilities in all states / jurisdictions Department of Motor Vehicles in all states / jurisdictions Department of Corrections in all states / jurisdictions, and my Attorney Office of Record, as an Officer of the Court.

Information to be released / exchanged shall include results of the substance abuse clinical assessment; prior conviction and/or treatment; completion / non-completion of program recommended by this assessment; issues related to compliance with program rules; progress while in treatment; recommendations for continuing care; DSM diagnosis, assessment summary and the Form 508R.

I understand that this information will only be used in compliance with G.S. 20-17(m), 1987 Chapter 797, Senate Bill 508, as amended. I understand that verification of my compliance with the assessment, treatment, or education called for is necessary for my driver's license to be reinstated, and to comply with a court judgment, if so ordered by the presiding judge. In addition, this information is reported for the purpose of tracking, DWI intervention, and compliance.

The doctrine of informed consent has been explained to me and I understand the contents to be released, and the need for the information. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Client Records, 42, C.F.R. Part 2 and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations.

I hereby acknowledge that this consent is made freely, voluntarily and without coercion, and will be considered valid until reinstatement of my driver's license. (no more than 1 year from date of signature I further acknowledge that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it This consent expires automatically or as follows: 1 year from date of

Client Signature and Date*

(Client or Parent / Legal Guardian)

S&H Youth and Adult Services, Inc.

S&H Youth and Adult Services, Inc.

As a AATC of S&H Youth and Adult Services, Inc. Treatment Program client, the following treatment conditions, guidelines and requirements have been explained to me:

1. I am expected to attend all sessions and to notify my counselor if I will be absent. One absence is allowed. No call no show fee is $30.00 is required after 2 absences, upon 4 one must re-start the program & pay balance for hours previously attended. 2. I understand that I am to actively participate in the group process and comply with the treatment plan that is developed and agreed upon with my counselor. 3.Abstinence from alcohol and mood-altering drugs is required 7 days a week, 24 hours a day while enrolled in treatment. Any difficulties with abstinence are to be reported to my counselor, and I understand that breathalyzing/urinalysis is utilized as a part of the treatment program. 4.Should positive breathalyzer/urinalysis occur, or should other information come to light regarding diagnostic status, I understand that I will be staffed for further treatment recommendations. My treatment may be extended at additional cost to me. 5.I am expected to maintain the confidentiality of other clients, just as the treatment staff will respect my right to confidentiality and will not release any information regarding me and my treatment without my consent. I will not discuss other clients outside the treatment setting. 6.I understand the treatment program sometimes invites clients to participate in therapeutic physical activity. Such programming is well supervised by clinical staff, and participation is on a voluntary basis. If I choose to participate, I understand I do so at my own risk, and AATC of S&H Youth and Adult Services, Inc. is not liable for any injuries that may occur. 7.I am aware that drugs, paraphernalia, or weapons, concealed or visible, on the premises of the AATC of S&H Youth and Adult Services, Inc. are prohibited. 8. All Treatment fees are to be paid in full before successful completion verification will be provided. 9.It is the client's responsibility to notify counselor or DWI Services of any court dates, needed paperwork, changes in contact information, and changes in legal status.

1.Maintain confidentiality 2.Respect fellow group members 3.No food or drinks are allowed in the group rooms. A break will be provided. 4.Pagers and Cell Phones are to be turned off upon entering group.

Inclement Weather Policy: AATC of S&H Youth and Adult Services, Inc. does not close at the first sign or threat of snow or ice. The facility does not follow the Local Government/Courts or school schedule. A decision will be once conditions warrant such. There will be a voicemail message on AATC of S&H Youth and Adult Services, Inc. Voicemail (704-603-8285)if the agency opts to close. If you have any concerns or Questions, feel free to call. Closing is also listed on Channel 9. In the event of Ice, there is a possibility of power outages and power surges in which case the phone System may shut down or revert back to default. Leave a message and use your best Judgment. Generally, if the agency is open, you will be able to reach someone by phone.

Client Signature*

Date*

Date

S&H Youth and Adult Services, Inc.

Where am I now in the process of achieving this outcome? (Include progress on goals over the past years, as applicable).*

What do you want to get out of this class?*

Client name*

S&H Youth and Adult Services, Inc

Progress toward goal and justification for continuation

I confirm and agree with my involvement in the development of this PCP. My signature means that I agree with the services/supports to be provided. I understand that I have the choice of service providers and may change service providers at any time, by contacting the person responsible for this PCP.Supports to Call: S&H Youth and Adult Services, Inc crisis line 704-603-8285.

What are some Triggers you may have to drink alcohol and/or use drugs?*

List people who will support your sobriety and help you to stay sobe.*

Client Signature*

Date*

Date

S&H Youth and Adult Services, Inc.

Admitting Date*

Date

Client Strengths/Abilities*

Presenting Concerns*

Arrest Date*

Date

Conviction Date

Date

Arrest County*

Docket#

DMV State & License#*

BAC

S&H Youth and Adult Services, Inc.

Demographic Face SheetSimple Screening Instrument for Alcohol and Other Drugs (SSI-AOD)

DEMOGRAPHIC FACE SHEET

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION CRIMINAL JUSTICE SYSTEM REFERRAL

GROUP RULES

DWI PERSON-CENTERED TREATMENT PLAN