Stepping Stones of Atlanta - Application for Admission

Stepping Stones of Atlanta Recovery Residences, www.SteppingStonesofAtl.com. Mailing address: 5953 Krim Drive, Norcross, GA 30093. Questions? Call Chris Zollman at 678-668-3426. At Stepping Stones, the goal is permanent recovery from drugs and alcohol. Minimum requirements for admission: 1. Commitment to stay at least 6 months. You may stay longer. 2. Complete abstinence from all mind- and mood-altering substances: illegal drugs, alcohol, prescription drugs (certain medical exceptions can be made), or any other substance used to alter your mind or mood. We screen for drugs and alcohol several times a month, and every screen is lab-verified. We do not accept residents taking Vyvanse, Suboxone or Subutex. A failed screen means immediate discharge (zero tolerance). 3. You must be willing to get a sponsor within 1 week and meet with your sponsor once a week. 4. You must be willing to learn the 12 Steps; active participation in all groups, step-work with your sponsor, and attendance at outside 12-Step meetings is mandatory. 5. Complete willingness to follow all rules and directions. 6. You must have a job, be actively seeking employment (verified), attend an outpatient program, or attend school full time during the day. 7. No Fraternization for a minimum of 60 days: no dating or spending time with members of the opposite sex; existing relationships must be put on hold for 60 days. 8. Attend the three mandatory weekly meetings, plus at least two additional 12-Step meetings of your choice, and other mandatory meetings, retreats and functions.

I voluntarily consent to services provided by Stepping Stones of Atlanta, including residential services, consultation, and therapeutic services. Failure to participate in recommendations may result in termination or referral to another setting of care. No information will be released outside the team without express written consent. I consent for the team to share information about me and my substance abuse or mental health records in order to provide me treatment services. I understand that I must provide truthful information about my medical and legal status. I understand that Stepping Stones of Atlanta will not harbor fugitives from the legal system. I also agree that Stepping Stones of Atlanta is not liable for any injuries and/or death (overdoses, suicide). I UNDERSTAND THAT ALL FEES ARE NON-REFUNDABLE.

I request and authorize Stepping Stones of Atlanta (5953 Krim Drive, Norcross, GA 30093, (678) 668-3426) to disclose to or obtain from the person/agency below the following records, if available: History and Physical exam; Alcohol and Drug Abuse Treatment records; TB (tuberculosis) results. I understand that my records are protected under the federal confidentiality regulations for alcohol and drug abuse patient records (42 CFR Part 2) and cannot be disclosed without my written consent unless the regulations say otherwise. HIV-, STD- and TB-related information is protected by State law. I may revoke this consent in writing at any time, except where action has already been taken in reliance on it. This consent expires once all transactions on accounts related to services provided to me are complete.

Stepping Stones is based on community living and the 12-step program. You are living in an alcohol- and drug-free shared recovery residence as a lodger sharing a housing unit, not as a tenant with rights to, or exclusive possession of, any space. This agreement does not bind either party to a specific length of stay, and either party may end services at any time. All program fees must be paid in advance, and no refunds will be given for any reason. Management reserves the right to end this agreement. Residents must give 30 days written notice of intent to leave. If discharged, you must vacate immediately, turn over all keys, security cards, parking passes, etc., and remove all personal property under staff supervision. Property not removed within 72 hours will be disposed of as staff deems necessary.

IMPORTANT: If someone else will pay your program fees (parents, a church, etc.), they MUST sign in order for you to complete intake. If you cannot fully pay your program fees and support your other expenses while at Stepping Stones, you must have a responsible party or we will refer you to a program that is a better fit. Responsible party statement: I am the responsible party for the payment of this resident's program fees. I understand the amount due and the date it is due. If the resident is discharged for any reason with a balance due, I will pay the balance within 48 hours. I understand all fees are non-refundable.

The confidentiality of people in recovery living in a Supportive Living Environment is protected under Federal Law 42 CFR: no one outside the program may learn of a client's participation without the client's permission. No information about a client may be released outside the program unless: (1) the client has signed a consent form for that person/agency; (2) a court order is issued to Stepping Stones; (3) medical personnel need it in a medical emergency; or (4) the client threatens to harm themselves or someone else. Federal law does not protect a client who commits a crime against anyone at Stepping Stones, and does not restrict reporting child abuse/neglect to State and local authorities. I agree to tell staff if any of my peers reveal information about themselves or another client that may be a cause for concern.

If you want us to send your attorney or P.O. anything, you must fill out their information completely, and it must be current. We will not accept verbal or emailed updates. I authorize Stepping Stones of Atlanta and its representatives to disclose information to, and discuss my participation with, the people below. In an emergency or a relapse (which is a life-threatening emergency), I give Stepping Stones permission to notify ANYONE associated with me whose contact information they can obtain.

List ALL medications you are taking. If your medication or dosage changes in ANY way, notify staff right away. Failed drug screens caused by missing or false information here are grounds for immediate discharge.

Urine alcohol tests are very sensitive and can detect trace amounts long after use. Exposure to non-beverage alcohol sources can cause a positive result. It is YOUR responsibility to read labels and limit exposure. Use of these products will NOT be accepted as an excuse for a positive test. When in doubt, do not use, consume or apply. Cough syrups/liquid medications: alcohol- or DXM-containing syrups (e.g. Nyquil) are prohibited; review all prescription and OTC meds with your house manager before use. Non-alcoholic beer and wine (O Douls, Sharps) contain residual alcohol; do not consume. Foods: vanilla/almond extract, liquid herbal extracts, communion wine, food cooked with wine, and flambe dishes must be avoided. Mouthwash and breath strips containing ethyl alcohol are not permitted; use alcohol-free versions. Hand sanitizers contain up to 70% alcohol; avoid excessive use and wash with soap and water instead. Hygiene products (aftershave, cologne, hairspray, mousse, astringents, bug spray, some body washes) must be used sparingly. I have read and understand my responsibilities and agree to abide by this contract. If I breach it, I am choosing to leave the program and accept any legal consequences if I am mandated to complete the program.

Thank you for applying. After you submit, call Chris Zollman at 678-668-3426 to finish your intake. Bring a photo ID and, if you will have a vehicle, copies of your driver license and insurance card. All residents must pass a drug test to move in.