The Shepherd's Shelter

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					The Shepherd’s Shelter
Adult Substance Abuse Center

236 Bridgett Drive Mt. Sterling, KY 40353 Intake Packet
The Shepherd’s Shelter is very pleased that you have recognized a need for help in the areas that have been controlling your life. We are glad you have contacted us here in Mount Sterling to help you that that initial steep toward a new life in Christ. You now have an opportunity to join others who have made this commitment to go on with their lives. It is very important that you understand who we are and what we expect before enrolling, so that you will be confident you are entering the right program for you. Therefore, you will need to read all this material thoroughly and make a thoughtful decision based upon your desire to have a change in your life. NOTICE: ANYONE ENTERING REHAB WITH A PRE-EXISTING ILLNESS WILL NOT BE TREATED THROUGH THE EMERGENCY ROOM. CLIENTS MUST BE ABLE TO PAY FOR TRANSPORTATION TO A LOCAL PHYSICIAN ($25) AND FOR THE VISIT, MED, ETC. AND HAVE THE CONDITION UNDER CONTROL BEFORE ENTERING. IF THE PRE-EXISTING CONDITION BECOMES MORE PRONOUNCED THAN THE DRUG ADDICTION, REQUIRING FREQUENT VISITS, ETC. THE CLIENT WILL BE DISCHARGED, SINCE FREQUENT VISITS OUTSIDE IS NOT CONDUCIVE TO RECOVERY
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The Shepherd’s Shelter
Resident Application
236 Bridgett Drive, Mt. Sterling, KY 40353 Phone: 859-498-7111 Every question must be completed and your picture enclosed, before your application will be considered. Please be descriptive in your answers. You must call once each week to verify your continued interest in our program to keep your name on our active list. Place Your Picture Here

1. GENERAL Name: _____________________________________________________ Last First MI Maiden Present Address: _____________________________________________ City: ________________________State:__________Zip: _____________ Phone: ( ) ____________________

Referred to Shepherd’s Shelter by: _______________________________ In case of emergency Notify: ____________________________Relationship:_______________ Phone: ( )____________________(home)( )___________________ (work)( )______________________ Address: ____________________________________________________ City: _______________________State: ___________Zip: _____________ 2. PERSONAL Date of Birth: ____________ Age:______ Weight: _______ Ht:________ Birthmarks or tattoos ____________________________________________________________ ____________________________________________________________ Race: _____________ Social Security Number: _____________________ Driver’s license State and Number: _______________________________ What are your present living conditions? ___________________________ ____________________________________________________________ ____________________________________________________________

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How are you supported?________________________________________ Marital Status: Single: _____Engaged _______Common-law_______ Married ______ Separated ______ Divorced _______ What is your relationship with your husband/boyfriend now? ____________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Would you say that your spouse/significant other has a drug or alcohol problem? ____________________________________________________ ____________________________________________________________ Do you have any children?___________How many?__________________ Custody: (Me) ________ Other: __________________________________ Education/Training: Last grade completed: _________________________ Have you ever been in special education classes?____________________ ____________________________________________________________ Have you ever been involved in prostitution? ________________________ When and how long were you involved?____________________________ 3. EMPLOYMENT Do you work? __________ Where do you work? _____________________ What type of jobs have you held in the past? ________________________ ____________________________________________________________ ____________________________________________________________ When was your last job? ______________ Type of job? _______________ What kind of job or trade would you like to learn? ____________________ ____________________________________________________________ 4. LEGAL STATUS Have you ever been arrested? _________ How many times?____________ List all charges: _______________________________________________ ____________________________________________________________ ____________________________________________________________ Are there any pending charges against you? ________________________ Are you on probation/Parole? _______ Where?_____________________ For what? ___________________________________________________ Name of Probation/Parole officer: _________________________________ Address: ____________________________________________________ City: __________________________State _______ Zip: ______________
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County: _____________________Phone ( ) ______________________ Have you ever served time in prison? _______ When? ________________ Where? _____________________________________________________ ____________________________________________________________ Offense(s) / Crime(s)___________________________________________ ____________________________________________________________ ____________________________________________________________ Name of Lawyer: ______________________________________________ Address: ____________________________________________________ City: __________________________State_________Zip______________ Phone ( )____________________ 5. SPIRITUAL Are you a born again Christian? ___________ Do you believe in God? _________________ Have you ever been involved in groups such as Christian Science, Jehovah’s Witness, Mormonism, Scientology, TM, Eastern Religions, or others?________ If so, which one(s) _____________________________________________ ____________________________________________________________ How do you describe your relationship with God now? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 6. THE PROBLEM What do you consider your main problems? ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ What efforts, if any have you made to correct these problems? __________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Have you ever been in an out patient program? ______________________ Did you finish treatment? _______ Have you ever been to Detox? _______ How many times? _________ Did you finish? _____________ Have you ever been in other in patient programs?__________
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Please list: _______________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 7. HEALTH Write yes or no beside the following illnesses or conditions that you have had. If yes, please write the date, to the best of your knowledge. Scarlet fever _____ measles _____ Chicken pox _____ mumps _____ Whooping cough _____ small pox _____ Typhoid fever _____ cancer _____ Syphilis _____ gonorrhea _____ Diphtheria _____ pneumonia _____ Nervous breakdown_____ diabetes _____ Migraines _____ high blood pressure _____ Do you have a special diet requirement due to allergies or medical reasons? Explain _____________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ What is the average amount of each substance you have consumed daily? Alcohol _____ heroin ______ Cocaine _____ opiates ______ Glue _____ tobacco ______ Marijuana _____ crack ______ Crank _____ valium ______ Uppers _____ downers ______ Hallucinogenics _____ ecstasy ______ Meth _____ xanax ______ Other prescription drugs: (list name and amount) ____________________ ___________________________________________________________ Other drugs: (list name and amount)______________________________

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

STATEMENTS OF RELEASE
I certify that all information here is accurate and true to the best of my knowledge. I understand that any false or incomplete information may result in disqualification of any application for entrance. Signed: ______________________________________________
Applicant Date

If forms were physically completed by anyone other than applicant, fill in below. Person _______________________________________________ Relationship to Applicant: _________________________________ Do you understand that learning disabilities severe enough to hinder cognitive abilities with application and coordination motor skills, may disqualify an applicant from eligibility for this program? Yes___ No ___ It is hereby understood that Shepherd’s Shelter is not responsible for any resident’s personal property left, lost, or stolen while in the program. I agree that any property or money left at Shepherd’s Shelter over 24 hours from my departure date, announced or unannounced, becomes the property of Shepherd’s Shelter. Signed: ______________________________________________
Applicant Date

It is further understood that I release Shepherd’s Shelter/Ross Rehab from all financial responsibilities in case of an accident, injury, illness or other imponderable misfortune. Signed: ____________________________________________
Applicant Date

It is further understood that I release the right to Shepherd’s Shelter/Ross Rehab to search my personal effects, make room searches, make a physical search and do drug testing without prior notice to me. Signed: _____________________________________________
Applicant Date

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

Procedure for Incoming Referrals
Clients wishing to enter Shepherd’s Shelter Adult Substance Abuse Treatment Center must contact our intake staff. The client seeking entry must make this contact personally. The Intake Staff are the only people who can accept referrals. 1. Arrangements for entrance MUST be confirmed prior to arrival. 2. Each client is limited to ONLY ONE suitcase. 3. Each client must provide Shepherd’s Shelter with a copy of Social Security Card and a picture ID. 4. In order to reserve a bed at Shepherd’s Shelter a $700.00 non-refundable first month’s payment MUST accompany the above –mentioned documents. 5. All clients not from the local area must arrive with documentation of their ability to return to their residence if/when needed. Cash, Check, or Money Orders ONLY are accepted. M.O. must be made payable to Shepherd’s Shelter/Ross Rehab. Monthly Tuition: $700.00 per month, due at the beginning of each month. If you are a 30 day resident or not court ordered, you must also pay an additional $200 for food cost for the first month since it takes 30 days to activate a food stamp card. Should you have any further questions, please contact our office. Office Hours: Monday-Friday: 9:00 a.m. to 5 p.m.

God Bless you in your decision!

____________________________________
Client Signature Date

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

What to Bring Maximum allowance items 1. Identification: Any 2 of the following:  Birth certificate  Driver’s License or other Picture ID  Social Security Card Personal Items:  Toothbrush, toothpaste, dental floss  Hair dryer  Nail clippers  Notebook paper, pen/pencils  Bible  Cosmetics  Brush, combs, hair scrunchies, etc.  Towels, wash cloths  Clothes basket & clothes hangers

2.

3.

Clothing: (please limit to one suitcase and overnight bag) Limit 1-2 of each item; limited closet space Women (suggested items; not required)  Dress  Blouse for church services  Skirt  Casual pants, Bermuda shorts  Blue jeans  T-shirts  Sweats  Coat and/orjacket  gloves  Socks  Casual and dress shoes (athletic, sandals, heels, flats)  Flip-flops (for shower)
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 Coat (during winter months)  Jacket or sweater  Appropriate sleepwear  Undergarments (no thongs)  House slippers  House coats/robes No clothing that has offensive logos or slogans is permitted. Tight fitting or seductive clothing is not permitted. No tank tops or tube tops. Keep jewelry to a minimum and preferably costume, since we are not responsible for lost or stolen items. Men (suggested items; not required)  Shirts (button front; polo; and t-shirts) both dress and casual— for church  Jeans  Casual pants/Bermuda shorts  Casual shoes (athletic shoes, work shoes)  Dress shoes  Belts  Underwear (no thongs)  Robe  House slippers  Flip flops (for shower)  Coat (winter months) and/or Jacket and gloves  Sweats, hoodies, caps, hats  Socks No clothing that has offensive logos or slogans is permitted. Shirt must be worn at all times outside your room. No pants that sag so as to show underwear are permitted. No tank tops (beaters) are permitted accept as an under shirt.

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

RESIDENT PHASE PROGRAM

4 WEEK EVALUATION: Resident is given an initial evaluation by the residential counselor and assigned work duties, given handbook and allowed to participate in every part of the program. At the end of the 4 week period the resident is evaluated again using data obtained from all staff concerning the resident’s readiness to enter the full program as a Phase I resident. Residents determined to be unprepared to meet the requirements of the program will be put on an additional 30 day observation or discharged. PHASE I: Length of Time: Approximately 5-7 weeks Requirements: 1. Resident will successfully complete all assignments in all classes on time. 2. Resident will have received no more than 1 write up for infractions of rules. 3. Resident will have received no more than 1 loss of daily privileges (smoke break, free time, etc.) 4. Resident will have lost ―no‖ visitation privileges. 5. Resident will have no dirty drug tests. 6. Resident will successfully complete 1, 4 hour visit with family/friends. 7. Staff will report seeing evidence of resident’s seriousness about the program. 8. No reports of slacking of work duties or bad attitudes when asked to perform a task. Resident must continue to find work to do on his/her own. 9. Resident will have recited all Phase I scriptures and have submitted an essay on his/her drug of choice. 10. Resident will successfully complete an interview with staff. PHASE II: Length of Time: Approximately 5-7 weeks Requirements:

1. Resident will successfully complete all assignments in all classes on time. Completed assignments shall be entered in an assignment log. 2. Resident will have received no write ups for infractions of rules. 3. Resident will have received no more than 1 loss of daily privileges (smoke break, free time, etc. 4. Resident will have lost ―no‖ visitation privileges. 5. Resident will have no dirty drug tests since last phase up. 6. Resident will successfully complete 1- 8 hour supervised visit with family/friends. 7. Resident will show evidence of leadership by staff reporting. 8. Resident will have recited all Phase II scriptures and have submitted an essay stating why he/she deserve a ―phase up.‖ 9. Client will conduct one AA/NA meeting 10

10. Resident will successfully complete an interview with staff. PHASE III: Length of Time: 6-8 weeks Requirements: 1. Resident will successfully complete all assignments in all classes on time. 2. Resident will complete reflection essays as assigned by counselor. 3. Resident will have received no write ups for infractions of rules. 4. Resident will have received no loss of daily privileges (smoke break, free time, etc. 5. Resident will have lost ―no‖ visitation privileges. 6. Residents will have no dirty drug tests since last phase up. 7. Resident will demonstrate leadership by organizing a fun night for residents as well as calling meetings to order, and helping to lead discussions in Community meetings and overseeing chores. Resident will show leadership by staying busy without supervision by staff. 8. SEE #7 IN PHASE 4. If you are unable/unwilling to accept this responsibility you will not phase up to phase 4. 9. Resident will successfully completed 1 - 24 hour home visit. 10. Resident will have recited all Phase III scriptures and have submitted an essay stating why he/she deserve a ―phase up.‖ 11. Resident will successfully complete an interview with staff. PHASE IV: Length of Time: 6 weeks or to end of 6 months requirement Requirements: 1. 2. 3. 4. Resident will successfully complete all assignments in all classes on time. Resident will lead at least one weekly AA/NA meetings. Resident will have received no write ups for infractions of rules. Resident will have received no more than 1 loss of daily privileges (smoke break, free time, etc. 5. Resident will have lost ―no‖ visitation privileges. 6. Resident will have no dirty drug tests since last phase. 7. Resident will demonstrate leadership by mentoring new residents leading morning walks and working with pastor to plan and organize a special Tuesday night church service. Any client unwilling to accept the responsibility and or accountability to report incidents of cardinal rule breaking to staff will not stay in this phase or advance to this phase. NOTE: Successfully completing this program is a requirement for graduation. 8. Resident will have successfully completed 1 weekend home visit. 9. Resident will complete a sobriety plan both short and long term. 10. Resident will complete a community service project. 11. Resident will create a plan for giving back to SS Rehab. 12. Resident will have recited all Phase IV scriptures and have submitted an essay stating why he/she deserves to graduate. 13. Resident will successfully complete an exit interview with staff.

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

STRIP/BODY SEARCH
I, _________________________________, a client/patient at the Shepherds Shelter/Ross Rehab (hereinafter ―the Rehab‖), understand that I am subject to a Strip/Body Search upon entrance to the Rehab, or at any time thereafter. I further understand that should drugs, drug paraphernalia or any other contraband be found on my body or in my possession, said item or items will be confiscated and appropriate legal action will be taken by the Rehab, its owners, agents or assigns. I have read the foregoing document and understand the terms and conditions of this document. This the ____ day of ______________________________, 20____.

________________________________ Patient/Client Shepherd’s Shelter/Ross Rehab BY:________________________ TITLE:_____________________

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

RELEASE OF MEDICAL OBLIGATION AND WAIVER
I, _________________________________, a patient at the Shepherds Shelter/Ross Rehab (hereinafter ―the Rehab‖), hereby release the Rehab, Pastor Wayne Ross, or any individual designated by the Rehab or Pastor Ross, working on behalf of the Rebab, of any responsibility, financial or otherwise, for any medical condition, medications required or physiological treatment, regardless of my medical and/or mental condition, pre-existing or acquired after becoming a resident at the Rehab. I further acknowledge and understand that the Rehab, Pastor Ross or any member, volunteer or individual designated by the Rehab will not be responsible for providing any form of medical treatment. I further release the Rehab, Pastor Ross and any other member, volunteer or individual associated or designated by the Rehab from any liability regarding any accidents, injuries or losses incurred while a resident at the Rehab. And, further understand and acknowledge that I am solely and financially responsible for any and all costs incurred for medical treatment therein. I give my consent for all medical records to be release to the staff at Shepherds shelter. This document is being signed by me, constituting my free act and deed with the knowledge that I do not have to sign this document, but choose to do so. This the ____ day of ______________________________, 20____.

________________________________ Patient/Client

Shepherd’s Shelter/Ross Rehab BY:________________________ TITLE:_____________________

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

FEE AGREEMENT

Pursuant to KRS 222.432 (4) (f), this Fee Agreement is made and entered into this day of as ―Rehab Facility‖); and (Hereinafter referred to as ―Resident‖); and (hereinafter referred to as ―Guarantor‖). , 2010, between, The Shepherd’s Shelter -

Ross Rehab, 236 Bridgett Drive, Mt. Sterling, Kentucky 40353 (hereinafter referred to

The Parties agree as follows:

1.

The term of this agreement is for _____ months, beginning on ____________ ______ and ending on _________________20____.

2.

The monthly fee for Resident residing at the Rehab Facility is $__700.00_____ and is due and payable on or before the 1 st of each month. Anyone paying after the 5th of the month will incur a $25 late fee with an additional $5 for each day thereafter the fee is unpaid. Depending upon the day of the month the client enters the program will determine their prorated amount the next month so that no one is charged for days they were not enrolled.

3.

Payment of the above-referenced monthly fee is guaranteed by ,

4.

If for any reason the monthly fee remains unpaid for a period of __15___ days after the above established due date, the Resident will be required to leave the Rehab Facility. If the Resident is at the Rehab Facility by means of a Court

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Order, the appropriate officials will be notified and the Resident will be immediately returned to jail where required.

5.

There is a strict no refund policy for any client who leaves or is discharged from this program early.

____________________________________ Supervisor

_____________________________________ Resident

___________________________________ Guarantor

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

VISITOR RULES 1. Visitors of Shepherd’s Shelter residents are required to leave all belongings (purses, tote bags, wallets, etc.) in their cars before entering the building. 2. Visitors must provide a picture ID to staff members before being allowed contact with residents.

3. Any contraband found on a visitor during a visit will be considered a deliberate attempt to make contact with a resident in order to jeopardize his/her sobriety and will result in immediate confiscation of the contraband. If the contraband is drug related, the police will be called and the visitor will be prohibited from future visits to the Shepherd’s Shelter. 4. Visitation is confined to the front lobby. Visitors are allowed to use the restrooms located in the lobby. Walking with or without residents around the building, down resident hall ways, or standing on the porch and front yard areas is prohibited. 5. The lobby/handicapped restrooms are for visitors only and residents will not be allowed in them. Visitors may not use any other restrooms in the facility. 6. Visitors may not leave the facility and return to their car during a visit. Once a visitor leaves, he/she will not be allowed back inside the facility or to make contact with a resident during the visit. 7. Shepherd’s Shelter management and/or staff reserve the right to require a search of any visitor who is suspected of having contraband on their person. We also reserve the right to drug test any and all visitors. Failure to comply with a random search will result in immediate expulsion from the facility. 8. Failure on the part of any visitor to comply with the rules explained herein will result in relinquishment of visitation privileges until/unless visitor agrees to comply with visitation rules. 9. We reserve the right to cancel visitation at any time without prior notice.

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Visitation Schedule
Every 1st and 3rd Sunday you must be here at 3:00pm and attend the class to be able to visit. There is no church on these Sundays. Church is at 6:00pm on the last Sunday of every month.

Sunday 3:00-5:00

Church Services
Saturday 6:00pm Tuesday 7:00pm

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

RELEASE OF INFORMATION
I, _________________________________, a patient at the Shepherds Shelter/Ross Rehab (hereinafter ―the Rehab‖), hereby authorize the Rehab, Pastor Wayne Ross, or any individual designated by the Rehab or Pastor Ross to release any information regarding my status at the Rehab, to requesting members of the Court and/or Judicial System, Family Member’s (unless otherwise requested not to receive information), any medical doctor known to be treated by me, and any other medical staff member regarding my stay and or progress while a participant in the program offered by the Rehab. I further authorize and release the Rehab, Pastor Wayne Ross, and any other person designated by the Rehab from any liability issue regarding the release of such information. This document is being signed by me, constituting my free act and deed with the knowledge that I do not have to sign this document, but choose to do so. This the ____ day of ______________________________, 20____.

________________________________ Patient/Client Shepherd’s Shelter/Ross Rehab BY:________________________ TITLE:__________________

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

RULES & REGULATIONS
We are a faith-based rehab; you are expected to comply with these rules. In the event that any rule is violated, you will receive a written warning. Upon receiving three (3) written warnings, you may be asked to leave the facility.

CHORES / TASKS
 You are expected to do daily chores, yard work, and maintenance while at this facility. You will be given a daily chore list that you must complete. When asked to perform a task, you are required to perform that task immediately. Failure to cooperate with Supervisors will result in a written warning.



CHURCH SERVICES / SUPPORT MEETINGS  You are required to attend all church services, group meetings, daily prayer circles, bible studies,
and other various meetings at the facility without exception. While in attendance you are expected to participate, be polite, respectful, and stay until you are dismissed.

CLOTHING  Any and all clothing items that display material deemed inappropriate—such as secular music
groups, alcohol, drugs, sexual innuendo, or any logo found improper by staff—will not be permitted.

PERSONAL BELONGINGS – PROGRAM COMPLETETION/DISMISSAL  Upon completion of this program, or in the event that you are dismissed from the program, you
must remove all personal belongings within 24 hours. Any and all personal belongings not claimed within 24 hours of leaving the program become property of Shepherds Shelter / Ross Rehab.

CONFLICT  Any problems or personal issues are to be taken first to your Supervisor or Staff Member. If
deemed necessary the Supervisor or Staff Member will speak with Pastor Ross or Dr. Donna Johnson on your behalf. If the problem or personal issue persists, or if you are in need of counseling, you may receive permission to sign-up to meet directly with Pastor Ross or Dr. Johnson.

CONDUCT
 You are expected to conduct yourself in a respectful manner and be cooperative with all Staff Members as well as other clients in residence. Disruptive attitudes, disrespect, horseplay, physical contact, violence, or the threat of violence of any kind will not be tolerated.

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

In the event that a client purposefully causes physical harm, willfully destroys property belonging to others or this Facility, or blatantly threatens a fellow client or Staff Member, the client will be immediately removed from the program and will further be subject to prosecution.

DATING  Residents are not permitted to have contact of any nature with clients of the opposite sex while in
this Facility. Nor are residential clients permitted to be alone with a person of the opposite sex at any time. While attending this program clients are not permitted to date, and public displays of affection (i.e. kissing, hugging, etc.) are not tolerated.

DEVOTION  You are required daily, to spend at least 30 minutes in religious and devotional time. This time is
for reading scripture, prayer, and meditation.

DRUG TESTING
 The Staff reserves the right to give random drug tests and/or random searches of your person, property, and room. These occurrences are under the sole discretion of the Staff and are not negotiable. The client will assess a twenty-dollar ($20) fee to pay for a drug screen in the event of any offpremises visitations



EMPLOYMENT
 No residential client is permitted to hold any outside employment while in this program.

FRONT OF PROPERTY
 You are never permitted on the front of the property for any reason unless you have been assigned yard work or outside maintenance in that area.

GAMES
 Games are allowed only at Staff discretion and/or your Supervisor’s express permission.

HOUSEKEEPING
   Male residents are NEVER permitted on female wings, nor are female residents permitted on male wings. You are not allowed to go into another person’s room for any reason. Since many people come through the Facility, we ask that you get dressed in your own room and also that males wear shirts at all times. You are not permitted to wear pajamas or slippers outside your wing. Your room must stay clean, organized and free of clutter at all times. You must clean your room every morning before your day starts - this includes making your bed. Do not leave your room in the morning until your bed is made. If you are in a room that sleeps two, you may only use one-half (1/2) of the closet and drawer space - no exceptions. You are expected to clean up after yourself. If you make any kind of mess you are to clean it up



 

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immediately.  You are not allowed in the kitchen for any reason unless you have kitchen duty.

   

You are to shower at least every day. Showers are limited to seven (7) minutes, and are restricted to designated shower times. You are not permitted to be in your room until after the set bedtime, except in the case of sickness, or to change clothes. Heat and A/C units in your room may only be turned on and remain on while you are in your room and must be turned off when you leave your room and ½ hour before bedtime nightly. You must be indoors by the bedtime curfew.

LAUNDRY
 You are allowed one (1) wash day per week. In addition to your regular laundry, your bed linens must be washed every week on that day. Laundry will cost $6.00 per week with a maximum of 2 loads.

LEAVING PREMISES
 You are not allowed, under any circumstances, to leave the premises without express permission and supervision. If you have permission and you do leave, you are to sign out and back in when you return.

MONEY & OTHER ITEMS
 You are not allowed to have any form of currency (money, food stamp card, etc.) in your possession at any time while you are a resident here, nor are you allowed to receive any other items directly. You must direct family and friends to give all monies and items to your Supervisor or Staff. Money will be locked in the safe. Your Supervisor will keep track of your money for you and will have to approve as well as supervise any spending. Your Supervisor will give you any personal items after they have been searched and approved. You are required to contribute a minimum of $200.00 cash or food stamp card per month for the cost of your food while you’re here. Your monthly fee to be a resident of this facility is $700.00.

 

MUSIC
  No radios, ipods or CD Players are permitted. You are not allowed to have a cell phone or pager - these must be turned into to your Supervisor.

SMOKING



Smoking is permitted, however, only in designated areas and at designated times. You are not allowed to exit the facility after bedtime to smoke.

SOCIAL GATHERINGS
 Social gatherings and contact between male and female residents and visitors must be in view of others at all times. You are never permitted to go anywhere on the property unsupervised with another resident or a visitor.

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TRANSPORTATION
 The church van is for resident transportation to and from church services and transportation to other Facility related or Facility approved destinations. If you need to go to court you must arrange a ride with a family member who has been pre-approved by pastor (no boyfriends or girlfriends will be allowed to transport you at any time).

VISITATION
  Visitation is permitted on Sunday (3pm-5pm). Visitors who wish to stay for church are welcome to do so. No visitors are allowed on this property to visit you or to drop off anything other than during regular visiting hours. Other visitation may be permitted only if Pastor gives prior permission. If someone shows up at a time other than regular visitation hours and they have not obtained prior permission from Pastor or your Supervisor, they will be asked to leave. An exception for a brief few minutes may be made if it is a family member from out of town. This exception is at your Supervisor’s discretion.

The Staff Members of Shepherds Shelter / Ross Rehab reserve the right to add to, delete, and/or change these Rules & Regulations at their discretion at any time
I have read and agree to adhere to the rules as listed above. I fully understand these rules. I further understand that if I break these rules I may be asked to leave this Facility. I also understand that if I am asked to leave, under no circumstances will any money paid be refunded—no exceptions.

Resident

Date

Director

Date

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

EBT/FOOD STAMP CARD USE AUTHORIZATION
I, _________________________________, a patient at the Shepherds Shelter/Ross Rehab (hereinafter ―the Rehab‖), hereby authorize the Rehab, Pastor Wayne Ross, or any individual designated by the Rehab or Pastor Ross, working on behalf of the Rebab, to use the EBT/Food Stamp Card that has been issued in my name while I am a resident at the Rehab. I acknowledge and understand that this EBT/Food Stamp Card is being used for my benefit and regardless of whether I am a resident of the Rehab for the complete month (i.e., thirty days) or less than thirty days, there will be no refund or release of any amounts on the EBT/Food Stamp Card, should I choose to leave the Rehab before the last day of the month for the monthly issue of funds on the EBT/Food Stamp Card. This document is being signed by me, constituting my free act and deed with the knowledge that I do not have to sign this document, but choose to do so. This the ____ day of ______________________________, 20____.

________________________________ Patient/Client

Shepherd’s Shelter/Ross Rehab BY:________________________ TITLE:_____________________

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Shepherds Shelter/Ross Rehab
236 Bridgett Drive shepherdshelter@bellsouth.net / shepherdshelter.com Mt.Sterling, Kentucky 40353 Phone (859) 498-7111 Fax (859) 498-7100

RECEIPT
DATE_____________________ PHONE NUMBER ____________________ FROM ___________________________________

$ ________________________________________DOLLARS o o o o PREPAY CASH MONEY ORDER CHECK

PREPAY FOR _____________________________________________
CLIENT NAME

RECEIVED BY ___________________________________________________

Pre Pay Client Agreement I understand that my pre-payment will hold the next available bed for me. If I choose to refuse the bed I understand that my pre payment is non refundable. However, if I am court ordered and the court chooses not to allow me to enter drug rehabilitation, my pre payment will be refunded IF I present a letter from the court that confirms that the court has denied drug rehab or rehab at this facility. If I do not contact the facility within 30 days of prepayment, in writing, I will forfeit my prepayment.

___________________________________ Name

_________________ Date

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