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Behavioral Connections of Wood County, Inc.
NEW AWARENESS PROGRAMS at Nazareth Hall
DRIVER INTERVENTION PROGRAM –ADULT MARIJUANA PROGRAM-INTENSIIVE EDUCATION
Please complete the following forms and return them to:
Behavioral Connections of Wood County, Inc.
P.O. BOX 29
Bowling Green, Ohio 43551
Attn: NAP
If you have any questions, call between 8:00 a.m. and 8:30 p.m. at
(419) 872-2419 ext. 3300 or Fax (419) 872-0926 email address; nswind@bc.wcnet.org
Fee: Is located on the payment sheet included with this packet. All fees must be paid in full one week before the program date.
Confirmation will be made to the court after payment. Any change from the original date after the court has been notified could result in
an additional $100.00 charge.
Acceptable Payment: Visa, MasterCard, Discover, American Express, Money Order, Certified Bank Check, or Personal Check.
Purpose: Your referral source has assigned a date to attend the program. These programs can fill quickly so please do not delay
returning the forms.
I understand the above and agree to unrestricted communication between Behavioral Connections of
Wood County and the Court of referral.
___________________________________________ _____________________
Client Signature Date
_________________________________________________________
Printed Name
__________________________________________ _____________________________
Court Case Number Court
Behavioral Connections of Wood County, Inc.
NEW AWARENESS PROGRAMS at Nazareth Hall
DRIVER INTERVENTION PROGRAM -ADULT MARIJUANA PROGRAM -INTENSIVE EDUCATION PROGRAM
RULES AND REGULATIONS PROGRAM DATE: ____________________
Arrive between 4:00 - 4:45 p.m.
1. This program begins promptly at 5 p.m. Thursday. Late arrivals will be refused entry and subject to a
rescheduling fee. Enter through the back door and take the elevator to the third floor for DIP check-in or the fourth floor for the IEP.
You may arrive as early as 4:00 p.m. You must bring a Photo ID to be admitted.
2. No alcohol or drugs should be taken 24 hours before the start of the program. If you are suspected of being under the influence or
having used alcohol or drugs, you will be tested. If positive, you will be required to leave the program and the court will be notified.
3. The meals are catered beginning Friday morning. A snack will be provided on Thursday evening but it is recommended that you eat
prior to your arrival. Vending machines will be available to you during the program at your own expense. It is recommended that you
bring nothing larger than a $5.00 bill. Do not bring food, snacks or beverages with you to the program.
4. Bring all toiletries and casual clothes. No clothing having alcohol logos, or drug references will be permitted. I-pods, pagers, cell
phones, headphones, computers, video games or electronics will be taken. Books and magazines are permitted. Towels, sheets,
pillows and blankets will be provided. You may bring your own pillow. You and your bags will be searched. Please see a list of
prohibited items included with this form.
5. Smoking Privileges may be allowed at selected times. All tobacco products must be in sealed packages. Chewing tobacco is only
allowed during smoke breaks.
6. Visitation and/or telephone calls from family and/or friends are not permitted. Emergency calls will be allowed. (Emergency Phone
# 419-832-0371). In this case only, you would be able to take the call and make arrangements to leave. It would be your
responsibility to provide BCWC with proof of the emergency before rescheduling your program date.
7. It is essential that you are an active participant, on time, complete all assignments honestly and to the best of your ability, attend all
program sessions and remain alert at all times.
8. Depending on the program you are attending, you will receive a Screen (3 Day DIP, IEP), Assessment (AMP) or Comprehensive
Assessment (6 Day DIP). If a further assessment or treatment is recommended, it is your responsibility to contact your referral source for
a list of approved providers.
9. All participants shall abide by Federal and State confidentiality regulations. This means that anytime during or after the program you
shall not reveal identities, names conversations, or personal information about or pertaining to participants of this program to another
participant or to anyone outside the program.
10. Prescribed medication must be brought in the original container with doctor information and product name visible. Only enough
medication for the weekend should be brought to the program. Over the Counter medications must be brought in the original sealed
container. No liquid cold medications will be permitted.
11. The particular program fee must be paid in full prior to attending a weekend. Any rescheduled program date will result in an additional
fee of $100 that must be paid prior to scheduling the new date. Changes to the original date must be approved by the referral source. If
you do not attend the program within one (1) year of payment, said payment is forfeited and you are required to pay the full fee again.
By signing this form, I acknowledge that I have read, understand, and received a copy of the above rules.
____________________________________________________ ___________________
CLIENT SIGNATURE DATE
_____________________________________________________ _____________________
PRINTED NAME ACCOUNT #
Revised 11-03-10
Behavioral Connections of Wood County, Inc.
NEW AWARENESS PROGRAMS at Nazareth Hall
DRIVER INTERVENTION PROGRAM -ADULT MARIJUANA PROGRAM -INTENSIVE EDUCATION PROGRAM
Complete these forms and return to:
Behavioral Connections of Wood Co.
27072 Carronade Dr. Suite A, B, C
Perrysburg, Ohio 43551
Attn: NAP (419) 872-2419
Client Information Sheet
________________________________________________________________________________________
Client Name Street Address
_________________________________________________________________________________________
City State Zip code County
_________________________________________________________________________________________
Home Phone Work Phone Cell Phone
_________________________________________________________________________________________
Date of Birth Social Security Number
_________________________________________________________________________________________
Court of Referral Drivers License Number
I have received information regarding the following documents. I understand the content of these documents and was able
to get clarification when needed.
Please initial next to each:
_____ Fee Statement and Payment Requirements _____ Client Grievance Procedures
_____ Confidentiality of Client Records (CFR42 pt 2) _____ Notice of HIPPA Privacy Practices
_____ Client Rights Policy and Listing of Clients Rights _____ Consent for Services
_____ Program Curriculum _____ Rules and Regulations
______________________________________________________________________ _____________________
CLIENT SIGNATURE DATE
_______________________________________________________________________________________ _____________________________
PRINTED NAME ACCOUNT #
Revised 11-03-10
Behavioral Connections of Wood County, Inc.
NEW AWARENESS PROGRAMS at Nazareth Hall
DRIVER INTERVENTION PROGRAM -ADULT MARIJUANA PROGRAM -INTENSIVE EDUCATION PROGRAM
WAIVER OF LIABILITY AND CONSENT FORM
Programs Site: Program Date: _________________________
Adult Marijuana Program Nazareth Hall
Intensive Education Ottawa County
72 Hr. Driver Intervention Program
Six Day Driver Intervention Program
8 Hr. Remedial Driving Program
WAIVER OF LIABILITY
THE UNDERSIGNED client, does for him/herself and for his/her heirs, executors, administrators, or representatives, hereby
release and indemnify Behavioral Connections of Wood County, Inc. and it’s directors, officers, employees and volunteers from any
liability (including attorney fees and costs) for personal injury, death, property loss, or others damage suffered or sustained by the
undersigned in connection with or arising out of Client’s participation in the Program described above, including transportation to and
from such Program, except such liability that is the result of the willful misconduct or gross negligence of Behavioral Connections or it’s
directors, officers or employees.
MEDICAL TREATMENT CONSENT
In the event of a medical emergency, Client hereby gives consent to (1) the administration of emergency medical treatment;
(2) the administration of emergency medical treatment deemed necessary by a doctor, hospital, or other healthcare provider; and (3)
the transfer of Client to any hospital reasonably accessible, as may reasonably be deemed necessary for the welfare of the Client.
CONSENT FOR PARTICIPATION
I consent to participate in the Behavioral Connections Program described above.
I have agreed to pay the fee associated with the program described above
I have agreed to provide the necessary forms, statements or affidavit required to waive this fee. I understand that if it is
determined that funds are no longer available or I was not entitled to payment for the DIP services provided for me I will be
required to pay the fee for the program described above.
______________________________________________________________________ _____________________
CLIENT SIGNATURE DATE
_______________________________________________________________________________________ _____________________________
PRINTED NAME ACCOUNT #
Revised 11-03-10
Behavioral Connections of Wood County, Inc.
NEW AWARENESS PROGRAMS at Nazareth Hall
DRIVER INTERVENTION PROGRAM -ADULT MARIJUANA PROGRAM -INTENSIVE EDUCATION PROGRAM
CLIENT RIGHTS
Persons who attend Behavioral Connections programs at Nazareth Hall have the following rights. [4-1-02 (HH) (1) through (HH) (17) ] :
(1) The right to be treated with consideration and respect for personal dignity, autonomy and privacy.
(2) The right to be informed of one’s own condition.
(3) The right to be informed of available program services.
(4) The right to give consent or to refuse any service.
(5) The right of freedom from unnecessary physical restraint or seclusion.
(6) The right to be advised and the right to refuse observation by others and by techniques such as one-way mirrors, tape recorders,
video recorders, television, movies or photographs.
(7) The right to consult with an independent specialist or legal counsel at one’s own expense.
(8) The right pf confidentiality of communications and personal identifying information within the limitations and requirements for
disclosure of client information under state and federal laws and regulations.
(9) The right to have access to one’s own client record in accordance with program procedures.
(10) The right to be informed off the reason(s) for terminating participation in a program.
(11) The right to be informed of the reason(s) for denial of a service.
(12) The right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, sex, national
origin, sexual orientation, socio-economic status, disability or HIV infection, whether asymptomatic or symptomatic, or AIDS.
(13) The right to know the cost of services, if applicable.
(14) The right to be informed of all client rights.
(15) The right to exercise one’s own rights without reprisal.
(16) The right to file a grievance in accordance with program procedures.
(17) The right to have oral and written instructions concerning the procedure for filing a grievance.
I have received a copy of my rights and all questions have been answered to my satisfaction.
___________________________________________________________ ______________________
CLIENT SIGNATURE DATE
____________________________________________________________ ______________________
PRINTED NAME ACCOUNT #
Revised 11-03-10
Behavioral Connections of Wood County, Inc.
27072 Carronade Dr. Suite A, B, C
Perrysburg, Ohio 43551
(419) 872-2419
AUTHORIZATION FOR MUTUAL DISCLOSURE
Client Name:___________________________ Date of Birth: ________________ SS# _____________________________
I authorize information to be exchanged between Behavioral Connections of Wood County, Inc. and
Bowling Green Municipal Court Oregon Municipal Court Perrysburg Municipal Court
Fulton County Eastern District Toledo Municipal Court Maumee Municipal Court
Fulton County Western District Northwood Municipal Court Sylvania Municipal Court
Other Court: ___________________________________________ Address: ___________________________________________
Attention: ____________________________________ Phone: ________________________ Fax: ________________________
The reason for this disclosure is: Satisfy Legal Requirements Other _____________________________________________
The specific information to be disclosed: Program dates, Admission Verification, Completion Report.
Integrated Summary Compliance Tracking Other: _________________________________________
I understand that the above items may include information regarding behavioral health recommendations that I have received.
Amount of information to be disclosed: Information covering current admission
Other ______________________________
This release will expire: At the formal and effective termination or revocation of my probation, or parole, or other processing under
which I was mandated into the above stated program.
The information released is for professional purposes only. Only the minimum amount of information needed to achieve the purpose may be disclosed. It may not be
provided in whole or part to and other agency, organization or person, other than that which is stated above. I have read and agree that all information was properly
completed prior to my signing this form, understand that his form is not required as a condition for treatment, and have the right to access the information to be
disclosed. I have the right to shorten or lengthen the authorization period at any time. This authorization is subject to revocation at any time except to the extent
that BCWC has already acted in reliance on it. The revocation must be in writing. I understand that BCWC cannot guarantee that the Recipient will not disclose my
health information to a third party and the Recipient may not be subject to federal laws governing privacy of health information. However, if the disclosure consists of
treatment information about alcohol or drug abuse treatment, the Recipient is prohibited from re-disclosure under federal law (42 CFR, Part 2) See notice below.
___________________________________________________ _____/_____/____
(Client Signature)
____________________________________________________________________ ______/______/______
(Witness)
Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by Federal confidentiality rules. 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 to whom it pertains or as otherwise permitted by 42 C.F.R., 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 information to criminally investigate or
prosecute any alcohol or drug abuse client. (These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.)
Revoked Authorization
Client has revoked this authorization: In Writing as of ______________________________________________
Date
Signature: ______________________________________________ Witness: ______________________________________________________
Behavioral Connections of Wood County, Inc.
NEW AWARENESS PROGRAMS at Nazareth Hall
DRIVER INTERVENTION PROGRAM -ADULT MARIJUANA PROGRAM -INTENSIVE EDUCATION PROGRAM
Behavioral Connections of Wood Co.
27072 Carronade Dr. Suite A, B, C
Perrysburg, Ohio 43551
Attn: NAP (419) 872-2419
PAYMENT INFORMATION
I HAVE ENCLOSED MY PAYMENT OF: $290 For the 48 Hour Intensive Education Program
$365 For the 72-Hour Drivers Intervention Program
$625 For the 6-day Drivers Intervention Program
$325 1st payment for the 6-day Drivers Intervention Program
$300 2nd payment for the 6-day Drivers Intervention Program
$325 For the Adult Marijuana Program
MY METHOD OF PAYMENT: Money Order or
Bank Check
Master Card
Visa
Discover
American Express
Credit Card # __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date: _______________
Authorization Code (Last 3 Digits on Back of Card): _________
Cancellation Policy
If you fail to attend a scheduled weekend program, there will be a $100.00 rescheduling fee. We do understand that unusual
circumstances arise which may have prohibited you from canceling your appointment or program with advance notice. Please discuss
these situations with us and under certain circumstances, we may determine to waive the rescheduling fee.
I give Behavioral Connections permission to charge my credit card for the program and amount selected above. I understand that
Behavioral Connections will keep my payment information confidential. By signing, I also acknowledge and understand the above
noted cancellation policy.
______________________________________________________________________ _____________________
CLIENT SIGNATURE DATE
_______________________________________________________________________________________ _____________________________
PRINTED NAME ACCOUNT #
Revised 11-03-10
