Application for Voluntary Admission by 2m9tDq

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									STATE OF SOUTH CAROLINA                                                     APPLICATION FOR VOLUNTARY ADMISSION
                                                                                      MORRIS VILLAGE
COUNTY OF                                                                ALCOHOL & DRUG ADDICTION TREATMENT CENTER
                                                                                       PART I – DEMOGRAPHIC INFORMATION




DEMOGRAPHICS:



Name of Proposed Patient                                              Sex                          Date of Birth            Age              Race




Marital Status                                        Social Security Number                       Religion




Street Address                                                   City, State                       Zip Code                 Phone Number


   Yes       No
Employed                   Employer                                                Occupation                               Monthly Income



Education (Check highest year completed):
  1      2   3    4   5     6      7   8     9   10    11   12       Voc/Bus/Tec     Att College      Graduate School     Unknown



Military Status:          Active        Inactive       Unknown




HOSPITALIZATION INSURANCE: (Including group insurance, Medicare, Medicaid, Champus, etc.)




Policy No. or HIB                      Name of Insurance Company                          Address



If group insurance, name and address of employer


Pre-Certification Required             Yes       No




                                                                                                                   I.D.




SCDMH FORM
APR. 99 (REV. AUG. 2012) M-340 PAGE 1 OF 6
                                      APPLICATION FOR VOLUNTARY ADMISSION
                                                  MORRIS VILLAGE
                                   ALCOHOL & DRUG ADDICTION TREATMENT CENTER
                                   PART I - DEMOGRAPHIC INFORMATION (CONTINUED)

CORRESPONDENT INFORMATION:
Please list the names, addresses and telephone numbers of 2 correspondents below. A correspondent should preferably be a close
relative and/or a person who is the most interested in having the proposed patient receive treatment.


Name #1                                                                   Relation to Patient


Mailing Address                                                           City                           State         Zip


Phone Number                                                              Additional Phone No.



Name #2                                                                   Relation to Patient


Mailing Address                                                           City                           State         Zip


Phone Number                                                              Additional Phone Number

FINANCIAL REPRESENTATIVE:
Please list the name, address and telephone numbers of the person to receive financial statements and other communications related to
personal financial affairs on behalf of the proposed patient.


Name                                                                      Relation to Patient


Mailing Address                                                           City                            State        Zip


Phone Number                                                              Additional Phone Number


REFERAL SOURCE INFORMATION:



   Referral Agent Signature                                              Date

   Referral Agent Name and Title (Please Print)
                                                                         SEND TO:
   Referral Agency                                                       Morris Village Alcohol and Drug
                                                                         Addiction Treatment Center
   Street Address                                                        610 Faison Drive
                                                                         Columbia, SC 29203
   City,                                     State   Zip                  Phone Number: (803) 935-7100
                                                                          Fax Number: (803) 935-7329
   Telephone Number                                                      I.D.




SCDMH FORM
APR. 99 (REV. AUG. 2012) M-340 PAGE 2 of 6
                                       APPLICATION FOR VOLUNTARY ADMISSION
                                                    MORRIS VILLAGE
                                    ALCOHOL & DRUG ADDICTION TREATMENT CENTER
                                       PART II – MEDICAL/CLINICAL INFORMATION

Medical Primary Care Provider:                                                               Phone No.:

Medical history and current medical symptoms or issues:




Medications:
List currently prescribed medications, including psychotropic and OTC (over-the-counter) meds. Include dosage, frequency, etc.
* If an attachment with this medication information is sent, this section does not need to be completed.
                Name                                  Dose                                  Frequency                        Physician
1.

2.

3.

4.

5.

6.


Has the individual been following his/her recommended medication plan?                 Yes       No Explain:



Is the proposed patient currently on opioid maintenance?           Yes      No If yes, please provide dosage and frequency:

List all hospitalization(s) for medical conditions in the past year:
1.                                                                                3.

2.                                                                                4.


Pregnant:        Yes       No        Unknown       If yes, how far along?                    Using substances while pregnant:     Yes       No      Unknown

Prenatal care:      Yes       No      If yes, please provide the doctor’s name and phone number:

Ambulatory:         Yes       No      Requires a cane, wheelchair or special accommodations:           Yes     No If yes, please identify the specific needs:



History of falls:      Yes       No          Receiving disability, Medicaid or Medicare:         Yes      No

If yes, please specify the reason(s):




                                                                                                I.D.



SCDMH FORM
APR. 99 (REV. AUG. 2012) M-340 PAGE 3 of 6
                                      APPLICATION FOR VOLUNTARY ADMISSION
                                                  MORRIS VILLAGE
                                 ALCOHOL & DRUG ADDICTION TREATMENT CENTER
                               PART II – MEDICAL/CLINICAL INFORMATION (CONTINUED)
Prior and Current Psychiatric Inpatient and Outpatient Treatment (most recent first):

             Facility/Hospital                                City, State                                      Date(s)                         Reason




Name of psychiatrist or other mental health professional:

Contact Information:

Psychiatric symptoms over the past year: (Check and explain all that apply)

Suicidal Ideations:           Yes       No                                        Suicide Attempts/Self-Harm Behaviors:            Yes   No

Homicidal Ideations:          Yes       No                                        Homicidal Attempts:      Yes           No

Destructive Behavior(s):          Yes        No                                   Violent Threats/Behaviors:      Yes         No

Hallucinations:        Yes       No                                               Paranoid Delusions:    Yes        No


Details:



Type of Alcohol and Other Drugs Currently Used:                                   Amount          Frequency                                   Last Date Used
(Please list the primary substance(s) of clinical concern first.)




Prior and Current A&D Inpatient and Outpatient Treatment: (most recent first)

             Facility/Hospital                                      City, State                                Date(s)                         Reason




In your professional judgment, is this person accurately reporting his/her alcohol and other drug use?                    Yes      No

Reason(s) the Proposed Patient Requires Inpatient Rather than Outpatient Care:



                                                                                           I.D.




SCDMH FORM
APR. 99 (REV. AUG. 2012) M-340 PAGE 4 of 6
                                     APPLICATION FOR VOLUNTARY ADMISSION
                                                 MORRIS VILLAGE
                                ALCOHOL & DRUG ADDICTION TREATMENT CENTER
                              PART II – MEDICAL/CLINICAL INFORMATION (CONTINUED)
Evidence of cognitive impairment:             Yes     No    If yes, please explain:


Head Injury:        Yes       No      Able to complete ADLs (Activities of Daily Living):        Yes        No


Estimated Intellectual Functioning:            Above average      Average        Below average           Diagnosed MR        Unable to determine

Deaf:      Yes        No      If yes, is a translator needed?    Yes        No Blind/visually impaired:          Yes    No

If yes, please specify the specific needs:

Signs of dementia or alzheimer’s:            Yes     No

          Please indicate if the proposed patient is:

          On probation or parole:            Yes    No                                  Involved with Drug Court:             Yes     No

          Serving a sentence:                Yes    No                                  Needing to return to jail:            Yes     No

          Awaiting Trial:                    Yes    No                                  Dealing with pending charges:         Yes     No
          Involved with DSS:                 Yes    No

          If “yes” to any of the above questions:

                A. Is inpatient treatment a stipulation?        Yes    No
                B. Give the nature and details of the involvement, including any charges and, if known, any hearing dates:




                C. Provide the name and telephone number of the relevant contact person(s):




Current living/housing situation:



Have any aftercare plans been arranged? Please explain:



Has the proposed patient received treatment at Morris Village before?           Yes     No

If yes, please list the year(s) of most recent admissions:

Please provide any additional information relevant to the proposed patient’s referral and treatment:




                                                                                                  I.D.




SCDMH FORM
APR. 99 (REV. AUG. 2012) M-340 PAGE 5 of 6
                                     APPLICATION FOR VOLUNTARY ADMISSION
                                               MORRIS VILLAGE
                                  ALCOHOL & DRUG ADDICTION TREATMENT CENTER
                                                    PART IV

                                                   NOTICE OF DISCHARGE RIGHTS

S.C. Code Section 44-52-30 (1976, as amended): Discharge of a Voluntary Patient

The head of a treatment facility may discharge a patient who has successfully improved to the point that hospitalization of the patient
is no longer necessary. The head of the treatment facility may also discharge any patient if to do so would, in his/her judgment,
contribute to the most effective use of the facility in the care or treatment of chemically dependent persons.

S.C. Code Section 44-52-40 (1976, as amended): Release of a Voluntary Patient

A voluntary patient, who has admitted him/herself to a treatment facility, or a voluntary person’s legal representative, legal guardian,
parent, spouse, or adult next-of-kin, whose on behalf admission to a treatment facility was requested, may request in writing the
release of the patient at any time after his/her admission. If the patient was admitted on his/her own application and the request is
made by a person other than the patient, release may be conditional upon the consent of the patient.

The request for release may be submitted to the head of the treatment facility or to any staff person of the facility for transmittal to the
head of the treatment facility. If the patient or another person on his/her behalf makes an oral request for release to any member of the
staff, the patient must within 24 hours be given assistance in preparing a written request. The person to whom a written request is
submitted shall deliver the request to the head of the treatment facility within 24 hours. (Saturdays, Sundays and legal holidays are not
included in this 24 hour period.)

Within 48 hours of delivery of the request for release to the head of the treatment facility, the head of the treatment facility must:
        (1) Release the patient, or
        (2) Initiate proceedings for involuntary commitment by filing with the court of the county where the patient is a resident or
            of the county where the patient is hospitalized, a petition alleging the patient is a chemically dependent person in need of
            involuntary commitment of judicial proceedings under Section 44-52-70.



APPLICANT: Please see below information and sign accordingly.

           I hereby make application for VOLUNTARY ADMISSION to the Morris Village Alcohol and Drug Addiction Treatment Center.

           1.    It is understood and agreed that if I am admitted, I will obey and be bound by all rules and regulations governing the
                 hospital and its patients.

           2.    By making this application, I give consent to the Morris Village Alcohol and Drug Addiction Treatment Center to
                 administer such standard medical, surgical or psychiatric treatment as is recommended.

           3.    I HAVE READ OR HAVE HAD READ TO ME THE ABOVE STATUES DESCRIBING MY DISCHARGE RIGHTS
                 AND THE LIMITATIONS ON THOSE RIGHTS AND I UNDERSTAND THEM.



Signature of Proposed Patient                                      Date


Signature of Witness                                               Date




                                                                                               I.D.




SCDMH FORM
APR. 99 (REV. AUG. 2012) M-340 PAGE 6 of 6

								
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