authorize Bloom Recovery Network LLC to disclose: Registration letter, attendance or lack of attendance, participation (understanding of objectives, behavior/response), cooperation with the DIP program rules and expectations, Program Completion Report, Certificate of Completion

This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). 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 42 CFR 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 42 CFR 2.12(c)(5) and 42 CFR 2.65.

I understand that I may be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or healthcare operations, if peremitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I have been provided a copy of this form. 

Bring clothes and personal hygiene materials to meet your needs for three days and three nights. Appropriate dress is expected (no cutoffs, tank tops, shirts with obscene slogans, short shorts, or headgear). Pajamas may not be worn outside of your room. You are to be showered and appropriately groomed.

1. REGISTRATION & CHECK-IN: Begins in the conference room at 4pm. Be on time — late arrivals will not be admitted or refunded. All personal items will be inspected; empty pockets and bring photo ID. Personal property may be searched at any time.

2. AFTER CHECK-IN: You must remain on site for the duration of the program.

3. ARRIVE SOBER & IN GOOD HEALTH: Anyone under the influence of alcohol or drugs will not be admitted. Staff may use reasonable suspicion and/or testing to verify. Do not use alcohol or recreational drugs for 24 hours before arrival. Possession of drug paraphernalia will lead to discharge and confiscation, and may be turned over to law enforcement.

4. FOOD & SNACKS: Sealed snacks are allowed; no opened containers once intake begins. The program does not provide food on day one (Thursday), so eat before check-in. Bring change for vending machines; hotel rooms have a microwave and refrigerator.

5. SPECIAL DIETS & ALLERGIES: We will accommodate medical dietary needs (food allergies, gluten-free, vegetarian/vegan, and religious requirements) with limited options. Bring extra food if you need a specific meal plan. Personal food preferences, dislikes, or voluntary lifestyle choices are not considered dietary accommodations and cannot be guaranteed. Proof of need for dietary accommodations may be requested.

6. MEDICATION: Bring prescription and over-the-counter medications in their original labeled containers, and only the amount needed for 72 hours. Medical emergencies will be referred to a local hospital.

7. CIGARETTES, TOBACCO & VAPES: Allowed only during designated breaks and designated locations. Violation may result in termination and a fine. Bring enough supply — no deliveries. Only brand-new, sealed vape devices are permitted; previously used or unsealed vapes are not allowed. No vaping/smoking in hotel rooms.

8. MEDICAL MARIJUANA: Permitted only with a valid prescription card and only in edible form. No marijuana vape pens or mods allowed; edibles will be handled as medication.

9. CONFIDENTIALITY: Any breach of confidentiality — sharing names, personal information, or photos of participants — will result in immediate dismissal.

10. HOTEL PHONE & ROOM RULES: Hotel phones are not to be used. Incidental charges may void program participation. Do not contact hotel staff without permission. Obey all hotel rules and respect property. Rooms may be searched by staff. Keep rooms clean and do not remove hotel items.

11. SUPERVISED FREE TIME & CURFEW: clients are allowed to be in the lobby, fitness center, business center, designated smoking area, or their own rooms. Under no circumstance is a client allowed to go into the parking lot or another person’s room. At 10pm clients must be in their rooms for bed check at which time room keys will be collected. Those not present at this curfew check will be considered AWOL. Clients are not permitted to leave their rooms until 7am. No loitering in the hallways. Staff must know where you are at all times. 

12. ELECTRONICS & VALUABLES: Cell phones allowed only in rooms and during breaks; phones should be off during sessions. Staff may collect phones or vehicle keys at their discretion. Laptops, tablets, and gaming systems are permitted. Keep valuables with you — the program is not responsible for lost or damaged items.

13. DELIVERIES & VISITORS: No personal deliveries without staff approval. Food deliveries are allowed only during meals and free time and must be delivered to the conference room for inspection. Family visits are not permitted. Deliveries made without staff inspection could result in program removal. VISITS FROM FAMILY/FRIENDS WILL NOT BE PERMITTED. Please inform family/friends of these rules.

14. PROHIBITED ITEMS & BEHAVIOR: No weapons of any kind. Gambling is prohibited. Code of conduct must be followed at all times. If dismissed for rule violations, no refund will be issued and referral sources will be notified.

15. CANCELLATION/RESCHEDULING: Bloom Recovery has a cancellation and rescheduling policy; ask staff or visit bloomrecoverynetwork.com for details.

16. TOLEDO CLIENTS (Perrysburg): Wear the provided bracelet at all times. Pool access only during break times and standard pool rules apply; no lifeguard on duty.

CODE OF CONDUCT

As a guest of Bloom Recovery Network’s Driver’s Intervention Program (DIP), you are expected to demonstrate full respect to everyone you encounter, and in return, you will be treated with respect. The program adheres to a zero-tolerance policy for harassment, including any sexually oriented remarks, sounds, or gestures, discriminatory remarks based on race, gender, religion, or other protected characteristics, bullying/intimidation of other clients, any deliberate or negligent action that endangers the safety or well-being of clients or staff. The program reserves the right to dismiss participants who exhibit unruly behavior or otherwise undermine the integrity of the program, to include: suspected substance use, recording sessions or sharing another participants personal information or disclosures outside of group, or any resistant or disruptive behavior that interferes with programming sessions. If you are asked to leave due to a rule violation, no refunds will be issued, and your referral source will be promptly informed of the reasons for your dismissal. Participants may request a review of a dismissal decision by contacting Kelly  Burden, Owner, within 24 hours of dismissal.

By signing below, I acknowledge that I have read, understood, and agree to abide by the Rules & Regulations and Code of Conduct outlined above.

SIGN BELOW FOR ACKNOWLEGEMENT OF READING THE PROGRAM RULES & EXPECTATIONS.