Entire_Intake_Packet by qingyunliuliu

VIEWS: 48 PAGES: 78

									                            Notice of Privacy Practices

                                  Yes House
                           Youth Entering Sobriety

                        404 NW 23rd Corvallis, OR 97330
                  (541) 753-7801         Fax (541) 753-7805


 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
  MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
       THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.



       We respect our legal obligation to keep health information that identifies
you private. We our obligated by law to give you notice of our privacy practices.
This notices describes how we protect your health information and what rights
you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
        The most common reason why we use or disclose your health information
is for treatment, payment, or health care operations.
Examples of how we use or disclose information for treatment
purposes are: setting up an appointment for you or getting copies of your
health information from another professional that you may have seen before us.


Examples of how we use or disclose your health information for
payment purposes are: asking you about your heath or vision care plans, or
other sources of payment; preparing and sending bills or claims, collecting
unpaid amounts (ether ourselves or through a collection agency or attorney).
“Health care options” means those administrative and managerial functions that
we have to do in order to run our office.

Examples of how we use or disclose your health information for health
care operations are: financial or billing audits; internal quality assurance;
personal decisions; participation in managed care plans; defense of legal
matters; business planning; and outside of your records.

We routinely use your health information inside our office for these purposes
without any special permission. If we need to disclose your health information
outside of out office for these reasons, we usually will not ask you for special
written permission.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
       In some limited situations, the law allows or requires us to use or disclose
your health information without your permission. Not all of these situations will
apply to us; some may never come up at our office at all. Such uses or
disclosures are:

   When state or federal law mandates that certain health information be
    reported for a specific purpose
   For public health purposes, such as contagious disease reporting,
    investigation or surveillance, and notices to and from federal Food and Drug
    Administration regarding drugs or medical devices.
   Disclosures to the government authorities about victims of suspected abuse,
    neglect, or domestic violence.
   Uses and disclosures for health oversight activities, such as for the licensing
    of doctors; for audits by Medicare or Medicaid; or for investigation of possible
    violations of health care laws.
    Disclosures for judicial and administrative proceedings, such as in response
    to subpoenas or orders of courts or administrative agencies
   disclosures for law enforcement purposes, such as to provide information
    about someone who is or is suspected to be a victim of a crime; to provide
    information about a crime at out office; or to report a crime that happened
    somewhere else
   Disclosure to a medical examiner to identify a dead person or to determine
    the cause of death; or to funeral directors to aid in burial; or to organizations
    that handle organ or tissue donations.
   Uses or disclosures for health related research
   Uses and disclosures to prevent a serious threat to health or safety
   Disclosures relating to worker’s compensation programs
   Disclosures of a “limited data set” for research, public health, or health care
    operations
   Incidental disclosures that are an unavoidable by-product of permitted uses
    or disclosures
   Disclosures to “business associates” who perform health care operations for
    us and who commit to respect the privacy of your health information

Unless you object, we will also share relevant information about your care with
your family or friends who are helping with your eye care.

APPOINTMENT REMINDERS
       We may call or write to remind you of scheduled appointment or that it is
time to make a routine appointment. We may also call or write to notify you of
other treatment or services available at our office that might help you. Unless
you tell us otherwise, we will mail you an appointment reminder on a post card,
and/or leave you a reminder message on your home answering machine or with
someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES
        We will not make any other uses or disclosures of your health information
unless you sign a written “authorized form.” Federal law determines the content
of an “authorized form”. Sometimes, we may initiate the authorization process if
the use or disclosure is our idea. Sometimes, you may initiate the process if it’s
your idea for us to send you information to someone else. Typically, in this
situation you will give us a property completed authorization form, or you can
use one of ours.
        If we initiate the process and ask you to sign an authorization for, you do
not have to sign it. If you do not sign the authorization, we cannot make the use
or disclosure. If you do sign one, you may revoke it at any time unless we have
already acted in reliance upon it. Revocations must be in writing. Send them to
the office contact person named at the beginning of this notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
     The law gives you many rights regarding your health information. You
can:

   Ask us to restrict our uses and disclosures for purposes of treatment (except
    emergency treatment) Payment or health care operations. We do not have to
    agree to do this, but if we agree, we must honor the restrictions that you
    want. To ask for a restriction, send a written request to the office contact
    person at the address, fax or Email shown at the beginning of this notice.

   Ask us to communicate with you n a confidential way, such as by phoning
    you at work rather then at home, by mailing health information to a different
    address, or by using Email to your personal Email address. We will
    accommodate these requests if they are reasonable, and if you pay us for any
    extra cost. If you want to ask for confidential communications, send a written
    request to the office contact person at the address, fax or Email shown at the
    beginning of this notice.

   Ask to see photocopies of your health information. By law there are a few
    limited situations in which we can refuse to permit access or copying. For the
    most part, you will be able to review or have a copy of your health
    information with in 30 days of asking us (or sixty days if the information is
    stored of-site). You may have to pay for photocopies in advance. If we deny
    you request, we will send you a written explanation and instructions about
    how to get and impartial review of our denial if one is legally available. BY
    law, we can have one 30-day extension of the time for us to give you access
    or photocopies if we send you a written notice of the extension. If you want
    to review or get photocopies of your health information, sent a written
    request to the office contact person at the address, fax or email shown at the
    beginning of this notice.

   Ask us to amend your health information if you think that it is incorrect or
    incomplete. If we agree, we will amend the information within 60 days from
    when you ask us. We will send the corrected information to persons who we
    know got the wrong information, and others that you specify. If we do not
    agree, you can write a statement of your position and we will include it with
    your health information along with any rebuttal statement that we may write.
    Once your statement of position and/or rebuttal is included in your health
    information, we will send it along whenever we make a permitted disclosure
    of your health information. By law, we can have one 30-day extension of time
    to consider a request for amendment if we notify you in writing of the
    extension. If you want to ask us to amend your health information, send a
    written request, including your reasons for the amendment, to the office
    contact person at the address, fax, or Email shown at the beginning of this
    notice.

   Get a list of the disclosures that we have made of your health information
    within the past six years (or shorter period if you want). By law, the list will
    not include: disclosures for purposes of treatment, payment or health care
    operations, disclosures with your authorizations, incidental disclosures,
    disclosures required by law, and some other limited disclosures. You are
    entitled to one such list per year without charge. If you want more frequent
    lists, you will have to pay for them in advance. We will usually respond to
    your request within 60 days of receiving it, but by law we can have one 30-
    day extension of time if we notify you of the extension in writing. If you want
    a list, send a written request to the office contact person at the address, fax
    or email shown at the beginning of this notice.

   Get additional paper copies of this Notice of Privacy Practices upon request. It
    does not matter weather you got one electronically or in paper form already.
    If you want additional paper copies, send a written request to the office
    contact person at the address, fax or Email shown at the beginning of this
    notice.

OUR NOTICE OF PRIVACY PRACTICES
       By law, we must abide by the terms of this Notice of Privacy Practices
until we choose to change it. We reserve the right to change this notice at any
time as allowed by law. If we change this Notice, the new privacy practices will
apply to your health information that we already have as well as to such
information that we may generate in the future. If we change our Notice of
Privacy Practices, we will post the new notice in our office, have copies available
in our office, and post it on our web site.

COMPLAINTS
       If you think that we have not properly respected the privacy of your
health information, you are free to complain to us or the U.S. Department of
Health and Human Services, Office for Civil Rights. We will not retaliate against
you if you make a complaint. If you want to complain to us, send a written
complaint to the office person at the address, fax or Email shown at the
beginning of this notice. If you prefer, you can discuss your complaint in person
or by phone.

FOR MORE INFORMATION
        If you want more information about our privacy practices, call or visit the
office contact person at the address or phone number shown at the beginning of
this notice.


COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint
with the program manager of Family Recovery, Nonprofit, Inc. or with the
secretary of the Department of Health and Human Services. You will not be
penalized for filing a complaint.

I, undersigned, have read this notice and have had an opportunity to ask
questions and discuss the contents of this notice with Family Recovery Nonprofit,
Inc. staff.


Client’s Name:                                   Date:

Parent/Guardian Signature:                                     Date:

Staff person/Tile:                               Date:
                       Family Recovery Non-Profit, Inc
                                518 SW 3rd St.
                             Corvallis, OR 97333
                       Business Office: (541) 738-6832
                Milestones Women’s Program: (541) 753-2230
                         Yes House: (541) 753-7801




Date:

Client Name:

Guarantor:

Relationship:

Address:


Phone:

DOB:

Social Security Number:

Employer:

Address:


Phone:

Wage/Salary:

Other Income:

Bank Account:




                          FINANCIAL INFORMATION
                   (to be filled out by parent/guardian)


VETERAN’S ADMINISTRATION NUMBER IF ANY:

PRIMARY INSURANCE COMPANY:
                                                   (Name of Company)

ID NUMBER:                           GROUP NUMBER:


Please list any Secondary Health Insurance Coverage Information
below:

SECONDARY INSURANCE:

ID NUMBER:                           GROUP NUMBER:


MEDICAL CARD:
                               (INCLUDE ALL LETTERS AND NUMBERS)

Client’s Salary:

Parent’s Salary/ Salaries:

Social Security:

SSI Federal Income:

Public Assistance i.e. food stamps, etc:

Dividends/ Interest:

Pension/ Unemployment/ Veteran’s Income:

Alimony/ Child Support:

Other Income:


TOTAL HOUSEHOLD INCOME:

          Family Recovery Non-Profit, Inc. d.b.a. YES House
             Program Description For Parents and Caregivers

What kinds of services does YES House offer?

YES House provides intensive residential services for up to 32 adolescents as well
as Level 1 and Level 2 outpatient care. Clients are assessed using American
Society of Addiction Medicine (ASAM) revised criteria to determine level of care
needed. Clients are reassessed every two weeks, more often if necessary, to
insure adequate service and appropriate treatment planning. The program
includes a licensed alternative school whose goal is to mainstream kids back into
established school systems (rather than the alternative school system they may
have come from).

YES House offers intensive family treatment and offers multi-family therapy
groups five times a week (Sunday, Tuesday, Wednesday, Thursday, and
Saturday). Family therapy is encouraged weekly, if not more, depending
on client needs. We also request that parents/guardians begin
treatment participation as quickly as possible following the intake
session. We ascribe to a multi model philosophy which includes the 12 Step
philosophy and provide discussion classes, workshops, and participation in
community based self help groups. The focus on recovery planning begins at
admission when an initial continuing care plan is formulated. This will be
modified throughout the course of treatment and completed prior to treatment
completion. We believe this focus and attention to “what happens next” is
critical to clients accepting the need for ongoing support once residential and
outpatient needs are met. Classes are taught daily in the areas of relapse
prevention, communications, anger management, and stress reduction. The
lessons learned from these classes are interpreted individually in a written Family
Recovery Plan that identifies household rules, boundaries, expectations, logical
consequences, and the identification of relapse triggers and strategies for
intervention. When clients manifest other serious mental health issues, referrals
are made for appropriate care, which may begin during the residential phase of
treatment.

YES House provides a system of phases that reflects the ASAM criteria. Since
ASAM Patient Placement Criteria came into being, we have felt it our obligation
to teach clients and their parents about the language that determines level of
care placement. Objectives are determined at intake and updated throughout the
life of treatment. As clients meet discharge to a lesser level of care,
arrangements are made to return the client back to their community and the
outpatient referral sources. This has resulted in shorter lengths of stay and less
time on the waiting list. Because the length of stay can be fluid, continuing care
planning begins at admission and we encourage parents/caregivers to be a part
of the process.

YES House is a regional program primarily serving clients from Linn, Lane,
Benton, Marion, Polk, Yamhill and Lincoln counties, although referrals can come
statewide depending on high risk factors (i.e. pregnant, homeless, or IV user).

What is the age range?

The age range is 12-18. An occasional 19 year old may qualify if they have not
completed high school and a team of professionals have determined that an
adolescent placement is more appropriate than an adult placement. Usually, the
older adolescent (18-19) will be in treatment for a shorter duration than their
younger counterparts. YES House also has some experience working with
younger clients (11-12 years old). Feel free to call the staff to discuss a younger
referral.

What does the schedule look like?

Treatment services begin with wake-up at 5:55am daily and conclude with a
multi-family therapy group, which ends at 8:15pm most evenings. Each day is
tightly structured with little free time. School runs year round with no breaks,
including weekends. (See attached)

How often can parents come and participate?

Parents are invited up to seven days a week beginning with the date of
admission. The intake and counseling staffs work closely with parents to insure
participation with respect to the parent’s schedules. Parents are also encouraged
to participate in a group or session and then take their child to an area
community support meeting. There is no provision for visiting in the weekly
schedule. Parents and other support persons participate in groups and
classes with their adolescent when on site.

How does one access services?

 There are three different avenues to access YES House. Each is dependent on
  an initial assessment that clearly identifies residential care as the appropriate
   level of service needed. This assessment is largely done by the outpatient
    referral source, although there are times we are approved to do the initial
                  assessment by the (private) insurance company.

A waiting list has been established for both the funded and private pay beds.
The length of time spent on the waiting list can vary. YES House manages its
own private bed waiting list. The wait for treatment can be as little as a few
hours or as long as several business days. The latter is dependent on the
insurance company’s protocols with respect to assessment and admission.

The public funded wait list can sometimes appear lengthy; although there are
measures an outpatient referral source can take to insure a quick response.
Forward your assessments, including a discharge summary, with
recommendations and a copy of the medical card as soon as possible. Discuss
the challenges your client has with the intake coordinator to assure an
understanding of your client and the family’s needs. Please let the intake
coordinator know whether the client is homeless, an IV drug user (don’t forget to
refer to the doctor), pregnant, or parenting.

The first avenue includes 12 beds that have been funded by OMAP and the
Department of Health services. Clients are eligible for these beds if they are
Oregon Health Plan enrolled. It also allows for a small number who are Oregon
Health Plan eligible, but who may not be enrolled. If you have a client who is
eligible but not enrolled, please help them complete the enrollment process with
the appropriate resource or agency.

The second avenue includes those with private health insurance. YES House is a
preferred provider for many insurance companies. Please help your client
telephone the number on the back of their card to insure the proper process is
followed. Many insurance companies prohibit admission into residential care
without first going through one of their own assessment specialists. If a client is
admitted into care prior to their first step, the insurance company could withhold
payment and the client would be financially responsible.

The third avenue includes those who may have depleted their insurance benefit,
may not have private insurance, but who prefer to pay out of pocket. We have
established a sliding fee scale to defray some of the cost of treatment.

How much does treatment cost for those who do not qualify for the 12
funded beds?

The daily rate for YES House is $300 per day, with a sliding fee scale, which
begins at $50 per day. Our goal is to not turn anyone away, however, treatment
does bear a cost. Please call and discuss your personal situation with the intake
coordinator.

What is the dress code?
YES House has a very strict dress code. Clients are allowed to wear plain, solid-
colored cotton sweats, t-shirts, and shorts. Logos, pockets, and drawstrings are
not allowed and will be removed at intake. (See Attached)


What if the parents, caregiver, or client cannot afford different clothes?

YES House maintains a small clothes bank and can supply sweats and shirts if
necessary, however, kids most often feel comfortable in something that belongs
to them, rather than something borrowed. We are always bringing things from
home to maintain a supply. We invite you, as you clean out your closets, to
remember us if you have any “dress code items” you want to get rid of.

Why a dress code?

We have learned, especially with the mandate toward shorter lengths of stay
(patient placement criteria), that the best way to get to the business of
treatment, is to remove the costuming that serves as a barrier to the process as
well as a mask. This decision has served us well and has resulted in a more
stable atmosphere and treatment retention. Posturing is reduced and most
clients have lost the appearance of violent potential when they otherwise would
not.

What are the staff qualifications?

Bruce Mathews, MD, a family practitioner who recently completed his ASAM
certification (American Society of Addiction Medicine) heads the clinical staff.
Paula Moniz-Trosen, LPC, is our clinical supervisor and has been at YES House
for 14 years.

We are in the process of applying for a mental health license and our on-line
clinical staff is laden with mental health experience. As our numbers grew with
clients who had mental health issues, diagnosis, and medications, it became
clear that we needed to develop the kind of staff who had experience beyond the
traditional drug treatment. Our staff includes Bernie McCarthy, LCSW, CADC III
and Gary Ladez, LCSW, as the lead therapist as well as a team of six others, an
MS/CADC II, and three others who are state certified. We also have Spanish
speaking staff.

For the past few years we have had a close relationship with Chemawa Indian
School and several tribal programs, providing treatment for their students. This
has lead to the establishment of contracts with most of the tribes in Oregon.

Who do I call for further information or to facilitate an admission?
Our administrative staff includes Windy Conway and Teresa Stoeckl; they can
help answer most questions. Please feel free to call her Monday through Friday
from 8 a.m. to 4:30 p.m.

Who do I call if I have a concern about the waiting list or the program
itself?

Tanya Pritt has been the Program Manager for the past 12 years. She is
available most of the time, Monday through Friday, and always on-call to the
program.


So, where are the kids?

The day begins at 6:25 a.m. with wake up. Breakfast is served at 6:30 a.m. and
put away at 6:50 a.m. (although kids are encouraged to finish eating what they
took.) Putting food away at a certain hour encourages even the most resistant
client to get up. We really aren’t hard-hearted, and if someone misses breakfast,
fruit and milk are available. After breakfast, a brisk walk, and morning chores
and hygiene, the kids begin their day in three (or four, depending on census)
groups that rotate through the academic classes, including a rigorous
fitness/wellness class. (This class occurs daily, twice on weekends).

Everyone comes together at lunch and many of the staff eat in the same dining
room. At mealtime, staff model appropriate, social behavior and encourage the
residents to do the same. Residents are encouraged to converse in quiet tones
and learn to visit with each other respectfully.

After lunch, group therapy begins. Again, the kids are assigned to different
groups, with different focuses and levels of participation.

After group, another class convenes that takes the same shape as the morning
academic classes. This class is followed by study hall and rotating groups to the
library.

Again, the kids come together for the evening meal, followed by family group
therapy on Tuesday, Wednesday, Thursday, and Sunday evenings as well as
Saturday morning. Twelve-Step support groups follow the evening meal on
Monday, Friday, and Saturday.

At 8:00 p.m. or a few minutes after, the kids proceed to their dorm areas. There
is little talking and they have an opportunity to journal, write letters, or just
enjoy some quiet after a long day. We believe the structure adds to the fact that
90% of our kids complete the treatment process.



My child has been prescribed medication. How is this handled?

Any medication needed by the client must be brought in “blister-packed”. Your
pharmacy can provide this service when you bring in an original or refill
prescription. (They will not blister-pack an already filled prescription.)

The staff cannot accept any prescribed medication that has not been blister
packed.

All medication is kept in a locked file cabinet.

The family/caregiver will be asked to sign a medication record form at intake,
which advises the guardian of our procedures. The Medical Director will review
the client’s medical history, as well as any medication orders, within 7 days of
admission. The Medical Director, at his discretion, may discuss any medical
issues or concerns with the counselor, parent, or the client’s own physician.

Clients are expected to be able to self-administer prescription medication
responsibly, under the observation of staff, or they will be deemed unable to
participate in this treatment setting.

How is my child notified when it is time to take medication?

Med calls occur four times each day. The staff person announces the procedure,
loudly, to all clients. Clients are expected to proceed to the medication station
and, in an orderly fashion, complete the process by signing for the medication
received and taking the medication under staff supervision.

If the medication has been prescribed for times other than the established “med
call” schedule, staff will insure the client is advised when to come to the
medication station.

What if my child acts irresponsibly with medication?

If your child has a history of abusing or declining medication as prescribed,
please inform the staff at intake. The staff then can discuss and decide what
methods or incentives to use to insure the medication is take responsibly.

Which pharmacies will blister pack my child’s medication?
Check with the pharmacies in your town. If they are unable to perform this
service, bring the original prescription to Rice’s Pharmacy or Bi-Mart in Corvallis
and they will do this for you. This service is covered under Oregon Health Plan
and may also be covered under your private insurance. Advise your insurance
company that we will be unable to accept your child in treatment without this
consideration.
                                  YES HOUSE
                             Youth Entering Sobriety

                      PARENT’S/ GUARDIAN’S RIGHTS

YES House will not discriminate in outreach, admissions, or treatment because of
race, religion, sex, ethnicity, age, handicap, or sexual preference. Furthermore,
YES House’s policy and procedures are designed to protect the rights of the
resident and their family.

YES House will make efforts to provide privacy and dignity for clients and their
families. Many of the services provided at YES House are in a group setting.
Each group will be informed about the need for confidentiality and will sign a
statement on the intake papers that they understand the confidentiality of the
program.

YES House will post rules at the Receptionist desk and each client, with their
parent/guardian will be expected to sign a statement that they have read the
rules and understand the rules.

YES House will maintain client records that are consistent with state statutes and
federal law.

To help insure that clients and their parent’s/guardian’s agree to treatment and
understand the YES Program they may be asked to actively participate in a
family treatment plan, and that will be documented through signature on the
treatment plan. In addition, all clients and parent’s/guardian’s will be asked to
sign the appropriate places on the intake forms that indicate that they are
applying for services at YES and are giving YES House permission to treat.

During the treatment planning process, the family will have the opportunity to
discuss the type of treatment to be undertaken, any alternative training or
treatment methods available, any risks that might be involved in training or
treatment; if any.

Clients or guardians have the right to refuse service at any time. Clients who are
court ordered for treatment may refuse treatment. The court ordered client who
refuses treatment might be discharged at that time and referred back to the
courts with the reason why treatment was discontinued.

The intake packet will contain a copy of the fee policy. Also, on the bulletin
board at the receptionist’s desk area will be posted a copy of the fee policy. At
the intake session, the client and parent/guardian will be informed of the fee
policy in easily understandable terms. No one will be turned away based on
inability to pay the cost of treatment.

All residents and their families have the right to be treated with dignity and
respect.

All residents and their families have the right to confidentiality in treatment.
Please see YES House statement on confidentiality for more details.

All residents or parent / guardian have the right to give written, informed
consent to treatment.

All residents and their families have the right to be informed of all services
available and the charges for these services.

All residents and their families have the right to be fully informed of the rules
and regulations governing conduct of residents.

All residents and their families have the right to manage their own personal
affairs.

All residents have the right to adequate food, housing, personal services, and
treatment.

All residents have the right to visits from family members, friends, and
advocates, legal and medical professionals that are consistent with the program
rules. Please read the visitation policy for further details.

All residents have the right to retain and use their own personal clothing and
belongings as permitted by space, consistent with the program rules and unless
this infringes upon the rights or safety of others. Parents/guardians are
expected to maintain the dress code and to not bring in clothing that is not listed
within the dress code guidelines for their children enrolled in YES House.

All residents, with their families, have the right to refuse treatment and to accept
the consequences of this right.

All residents have the right to privacy as is permitted by the living space available
within the program. Although YES House has minimal time within the structure
of the program to allow visiting, parents are encouraged to participate in
treatment as often as possible; up to seven days a week.
Clients maintain the right to leave the program at any time, and if they decide to
exercise this right, need to be aware of the legal or personal consequences of
leaving the program.

Clients, with their families, maintain the right for their own responsibility for
active participation in treatment, using the program and its staff as assistants in
their treatment process.

Clients and families maintain the right for their own responsibility to comply with
the rules of the program and their individualized treatment plan.

All residents have the right to practice their own religious beliefs that are
consistent with their treatment plan. Residents may be picked up by
parents/guardians to attend the church of their choice.

All residents of legal voting age have the right to vote. Materials will be provided
to facilitate registration.

All residents have the right to send and receive mail that is consistent with
program rules.

To be allowed access to community resources, such as recreational activities,
social service agencies, employment and vocational counseling services, and self-
help groups which are consistent with the resident’s treatment plan and written
program rules.

YES House prohibits:
a. Physical punishment
b. Seclusion in a locked room
c. Withholding shelter, regular meals, clothing, or any aids to physical
functioning.
d. the disciplining of one resident by another resident.
e. Sexual abuse or harassment. If any situation occurs that you believe
   resembles a-e above, please speak directly with your child's counselor or the
   program manager so that an efficient, effective intervention can occur.




Reference: Licensing Rule 413-210-040(1)
                      PARENT / GUARDIAN CONTRACT

I acknowledge that YES House cannot restrain my child if he/she wishes to
leave; however, I will be notified if he/she wishes to leave or leaves without
permission. I am responsible for the behavior of my child and agree to pay for
damages caused by my child.

I will follow the expectations for family members outlined in the visitations and
pass policies. I acknowledge that YES House encourages the family to
participate in all family sessions.

I will not use nicotine while visiting YES House. I will not bring alcohol, drugs or
paraphernalia into YES House, nor will I enter the facility with alcohol or drugs in
my system. I will check with the staff prior to bringing any items into YES
House.

In the event your child becomes ill or requires a physical and requires treatment
outside of YES House, staff will contact the Medical Director and follow his
advice. YES House will use dental services and eye services from providers
recommended by our Medical Director or for any non-routine problems.

If the situation is perceived as an emergency, staff will alert the emergency care
system, 911, and / or request an ambulance to transport your child to the Good
Samaritan Hospital emergency room. Staff will contact the YES House Program
Manager or designee. Please sign below if this plan meet with your approval.

_______________________            ________             _____________________

Parent Signature                   Date                 Staff Signature
         Date

_______________________            ________
Client Signature                   Date

***If this plan does NOT meet with your approval, please describe on back of
page your emergency care plan and sign in space directly below***

______________________             _________            _____________________

Parent/Guardian Signature          Date                 Staff Signature     Date

______________________             _________
Client Signature                   Date
I/WE AGREE ____ DISAGREE ____ THAT DURING MY CHILD'S TREATMENT
STAY AT YES HOUSE, I/WE WILL REMAIN:

___ ALCOHOL FREE      ___ NICOTINE FREE      ___ OTHER DRUG FREE

_____ I / WE AGREE TO ATTEND FAMILY PROGRAM ACTIVITIES AS
SCHEDULED BY MY CHILD'S COUNSELOR

_____ I /WE AGREE TO CHECK IN WEEKLY IN FAMILY GROUP ABOUT MY /OUR
PROGRESS

_________________________   __________ _____________________
Parent/Guardian Signature   Date       Staff Signature Date

_________________________   __________
Client Signature            Date
YES House Informed Consent/ Application Contract

CONFIDENTIAL STATEMENT:
YES House maintains confidentiality under state and federal statute (see 42 C.F.R.). No information will
be released to others nor will we request information from others without your written consent. Law
requires the following exceptions to this policy: information regarding child abuse, information indicating
imminent danger to self (suicidal threats) and imminent threats to other as reported by client. While we
may report program statistics, we will keep the personal identity of individuals confidential. Participants in
this program are expected to maintain confidentiality of all people involved in treatment activities with the
program. While this expectation is explicitly stated to all participants, confidentiality cannot be guaranteed
regarding other clients divulging information in group sessions. Clients are encouraged to disclose at the
level they find to be appropriate given their trust in other group members.

PROFESSIONAL DISCLOSURE STATEMENT:
Counselors working at YES House abide by professional ethics as prescribed by the National Alcohol and
Drug Counselors Association. Counselors are certified as CADC I or CADC II by the Addictions
Counselor Board of Oregon. The primary responsibility of counselors employed at the YES House is to
facilitate the recovery of clients with dignity and respect. YES House believes in promoting responsibility
for personal growth without blame, shame or violence.

Counselors may discuss their concerns on individual clients with the YES House Medical Director.
However, the Medical Director serves as a consultant and does not treat the clients. The Medical Director
reviews and updates medical policies and procedures, discusses current and ongoing medication for clients,
and consults with primary care physicians as needed.

(For Outpatient clients) Since clients are encouraged to accept responsibility for outpatient treatment, it
is expected that clients will attend all scheduled treatment appointments and remain abstinent from all mind
altering substances while in treatment. Consistent failure to attend treatment appointments or maintain
abstinence may result in termination from treatment and referral to an increased level of care. Indication of
two or more weeks having used drugs or alcohol is considered to be consistent use.

AGREEMENT TO BE TREATED:
I am applying for treatment services at YES House and agree to be treated by this program. Treatment
approaches employed at YES House include individual, group and family counseling and education. I
agree to maintain confidentiality as explained above. I understand that I am responsible for the cost of my
treatment determined by the sliding fee scale.

(For outpatient clients) I understand that I am expected to maintain abstinence from all mind altering
chemicals while in treatment and that the result of two or more positive drug screens may result in
termination from outpatient treatment and a referral to residential treatment.

I give permission to YES House to send drug urinalysis for testing to the designated Lab.

I am giving YES House permission to use their Medical Director to make the decision as to whether my
child needs to be seen for medical and/or psychiatric care. I give YES House permission to give insurance
and other third party payer information (including client identifying information, along with assignment
benefits) to appropriate institution and/or physician.

My parent / guardian and I have received a copy of our rights and responsibilities.


______________________________                         _______________
Client Signature                                       Date

______________________________                         _______________
Parent/Guardian Signature                              Date
                                    YES HOUSE
                                Youth Entering Sobriety


                DEVELOPMENTAL INFORMATION

Dear Parent/Guardian,

Your answers to the following questions may provide an important key to the solution of
your child’s problems. Thank you for taking the time to fill it out.


Clients Name:                                          Today’s Date:

Name of person Completing form:


Who are the significant members of your family at home and elsewhere:


Name                          Age              Relationship to client         Location




When did your child’s current problem begin?
How did he/she act before the problems started?

Has your child received inpatient or residential treatment before? If so, where and when
    Treatment Center Attended                                                           Dates Attended




If child was adopted, what information do you know about the biological parents?




Age adopted               Was child told of adoption                     if so, when?


PRENATAL AND BIRTH FACTORS



Was child full term?           Please explain any difficulties during pregnancy and
delivery, use of alcohol, drugs, tobacco or any difficult family issues.




                       EARLY DEVELOPMENT (0-5 YEARS)


Baby’s birth weight:      lbs.      Oz. Baby’s and mothers condition right after birth (any complications
                                            or problems)




           Any Problems with feeding (colic, spitting up, never satisfied, failure to gain weight)
Describe any sleeping problems (bedwetting, difficulty falling asleep or staying asleep, excessive sleeping)




At what age did your child begin walking:                      talking:              toilet trained:


Please check any of the following that apply:

Particularly active:               Very easily distracted:                       Fairly destructive:

Problems with coordination:                     Accident prone                       Frequently ill:

Particularly quiet or withdrawn: ___________

                          School Age Development (6-12 years)

                          How old was your child when he/she started school?

Any problems separating from parents?



Any difficulty in kindergarten with teachers or other children?




Did your child have any problem with teachers?                          If so, what were they?




Was your child in any organized activities such as scouts or sports?                      For how long?


If child quit, why?
                                      EDUCATION

        School                    Grades (from   to     )         Grades Received, any
                                                                      Problems?




                     CURRENT SOCIAL FUNCTIONING

                           Relationship with adults --- any changes?




Relationship with peers --- any changes?




                               FAMILY BACKGROUND

            Employment: mother:                                             father:

Ethnic background:

Religious backgrounds & current involvement:

Have family finances been easy, moderate or difficult?

Have there been recent changes in family finances?

                         FAMILY MEDICAL HISTORY
Please explain any family history (back to child’s grandparents) of alcohol or drug abuse,
emotional illness or hospitalizations, significant legal problems, sexual or physical abuse.
                                      FAMILY TIMELINE
Please outline family history from child’s birth to today including births, divorces, remarriages, deaths, and
                                                    moves:

DATE              EVENT
                  INFORMED CONSENT / TREATMENT ACTIVITIES
                              Program Participation Guidelines

On the date, _____________,    I, ______________________ agree to:

_____        1.     Participate in group therapy 5-10 times each week focusing on
                    denial, personal and family issues and the recovery process.
_____        2.     Participate in Alcohol, Tobacco, and other Drug education classes
                    5-7 times each week.
_____        3.     Participate in individual counseling sessions at least 1 time each
                    week, or as prescribed by my counselor.
_____        4.     Participate at a minimum of two 12 Step Recovery Meetings
                    each week.
_____        5.     Complete a written autobiography and Lifeline assignment,
                    sharing with parents/guardians, counselor and group (when
                    appropriate).
_____        6.     Complete written Step Work, 1-3, sharing with parents/guardians,
                    counselor and group (when appropriate).
_____        7.     Complete Steps 4 & 5, sharing with approved sponsor or minister.
_____        8.     Participate in 12 Step Philosophy groups and Big Book classes
                    1-3 times each week.
_____        9.     Participate daily in Academic Program, maintaining a minimum
                    C+ average.
_____        10.    By day 3 of treatment, I will invite my family and support
                    system to participate in treatment with me.
_____        11.    By day 7 of treatment, I will invite my siblings to join me
                    in family therapy or other treatment activities ( as determined by
                    my counselor.
_____        12.    Complete exercises, as assigned, in the Staying Sober Workbook-
                    Projects in Relapse Prevention and share in group with my family
                    And support system, and with the staff.
_____        13.    Complete a written Family Recovery Plan prior to beginning home
                    trial periods with my family/support system.
_____        14.    Complete a discharge plan prior to leaving YES House, including:
                    confirming a date for intake with a Continuing Care facility.
_____        15.    Participating in classes/groups focused on: Stress Management,
                    Anger Management, New-Think (Cognitive-Restructuring),
                    Journal Review, House groups (conflict resolution) and Nicotine
                    Free classes/groups.
_____        16.    Participate weekly in ________ issues group.
_____        17.    Participate daily in Structured Recreation and Physical fitness.


_______________________            ____________________          _________________
Client Signature                   Guardian Signature            Staff Signature
                      PHYSICAL FITNESS / RECREATION WAVER

  YES House offers a variety of physical / recreational activities throughout the weekly
 schedule. Clients have the opportunity to be involved in structured exercise programs,
   outings, and picnics. Any physical activities, as well as the treatment activities, are
                            supervised by YES House staff.

As part of the YES House adolescent treatment program, outdoor recreation in the form
of hiking and canoeing may be offered to each client who finishes the necessary
requirements.

Half-day outdoor hikes will be available for groups of four to five clients accompanied by
two staff persons. Clients will carry their lunches and extra clothes in backpacks. The
client will go in the program car to the trailhead, which is located about 30 miles from the
program. Hikes are supervised by trained outdoor leaders with current First Aid and
CPR training. Client must be recommended by their counselors for this activity.

Another activity may be a half-day canoe trip. A half-day training will be available to
clients who pass the swimming competency and are recommended by their counselor.
Four clients and two staff persons will use two canoes for flat-water training, which will
cover safety and operational procedures. All staff and clients will wear class V life vests
at all times near the water. Staff are trained outdoor leaders with First Aid, CPR, and
Red Cross water lifeguard certification. The following week a half- day paddle float on
the Willamette River will include no more than two clients and one staff person in each of
the two canoes. The route will be either Michael’s Landing to Hyak Park or Peoria
Landing to Michael’s Landing.

Please indicate any physical conditions, illnesses, allergies, or prior injury that may
inhibit some of client’s activity during treatment at YES House.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________

I hereby agree to assume all the risks in participating in the YES House residential
chemical dependency treatment program, and agree to hold YES House and its
employees blameless for any injury or liabilities to me arising out of participation in the
various physical / recreational activities offered throughout the program, and hereby
waive any and all causes of action which may occur to me. I attest and verify that I have
full knowledge of all the risks involved, and am physically able to participate in treatment
with exception made to the above noted ( by client) injuries / concerns. I will assume
and pay my own medical expenses and emergency expenses in the event of accident or
illness regardless of whether I have authorized such expense.


Client Signature: ___________________________                         Date: ____________

Parent Signature: ___________________________                         Date: ____________
          ADOLESCENT DRUG/ALCOHOL INVOLVMENT SCALE
                              (Revised from Adolescence and Alcohol by Mayer/Filstead)


            Name:                                  Age:                Male:         Female:   Date:

1.   How often do you use drugs or drink?
     a. never
     b. once or twice a year
     c. once or twice a month
     d. every weekend
     e. several times a week
     f. every day

2.   When did you last use drugs or alcohol?
     a. never used
     b. not for over a year
     c. between 6 months and a one year
     d. several weeks ago
     e. last week
     f. yesterday
     g. today

3.   I usually start to use drugs or alcohol because:
     a. to be like my friends
     b. to feel like an adult
     c. I like the effect
     d. I feel nervous, tense, full of worries or problems
     e. I fell lonely, sorry for myself

4.   What have you drank?
     a. wine
     b. beer
     c. mixed drinks
     d. hard liquor
     e. substitute for alcohol: paint thinner, cough medicine, mouthwash, hair tonic, etc.

5.   What drug(s) have you used or tried? (circle all that apply)
     a. marijuana
     b. inhalants (sniffing glue, gas, paint, rush)
     c. amphetamines (uppers,speed,crank)
     d. barbiturates (downers, Quaaludes, valium)
     e. hallucinogens (acid, mescaline, PCP,STP, mushrooms)
     f. Others (cocaine, heroin, crack)

6.   How do you get your drugs or alcohol?
     a. supervised by parents or relatives
     b. from brothers or sisters
     c. from home without parents knowledge
     d. from friends
     e. from “dealer”

7.   When did you first use drugs or alcohol?
     a. never
     b. after age 15
     c. age 14 or 15
     d.   between 10and 13
     e.   before age 10

8.   When do you usually use?
     a. parties
     b. during afternoon, evening
     c. before or during school
     d. before I go to bed (to help sleep)
     e. in the morning or when I first wake up
     f. whenever available

9.   How did you use when you used?
     a. drinking
     b. smoking
     c. swallowing or eating
     d. snorting
     e. inhaling
     f. injecting

10. Who did you use with?
    a. with friends my own age
    b. with older friends
    c. with brothers or sisters
    d. alone
    e. parents or relatives

11. What effects have you had from drugs or alcohol?
    a. good feelings
    b. very “high”
    c. became ill
    d. “freaked out”
    e. used heavily and the next day couldn’t remember what happened
    f. passed out

12. What effects have drugs or alcohol had on your life?
    a. has caused me to neglect my family or friends
    b. has interfered with talking to someone
    c. has prevented me from having a good time
    d. has interfered with my school work
    e. have lost friends because of using drugs or alcohol
    f. has gotten me into trouble at home
    g. was in fight or destroyed property
    h. has resulted in accident, an injury or hospitalization
    i. has resulted in arrest or being punished at school for using

13. How do you feel about your drug/ alcohol use?
    a. no problem at all
    b. I can control it, and set limits myself
    c. I can control myself, but my friends easily influence me
    d. I often feel bad about my using drugs or alcohol
    e. I need help to control myself
    f. I have had professional help to control my alcohol/drug use

14. How do others see you?
    a. as using less than my friends
    b. as using about the same as my friends
    c.   my family or friends advise me to control, cut down or stop my drug/alcohol use
    d.   my family or friends tell me to get help for my drug/ alcohol use
    e.   my family or friends have already gone for help for my drug/ alcohol use
                      PRE-TREATMENT MENTAL HEALTH SURVEY


  Client:                                         Date:                              Counselor:
Please fill out this form and give it to your counselor. Your responses to the following questions will help
us provide the most effective services to you.


                        Please rate how much you have been effected by the following

                                   Not at all      Mildly          Moderatel    Severely Extremely
                                                                   y
Concerns about your body or
physical health
Thoughts or behaviors you do
over and over again
Unusually high energy
Feeling sad, blue or depressed
Anxiety, nervous or tension
Anger, hostility or irritability
Fears of things or places
Unreal, strange or “bizarre”
thoughts
Have you been hit, kicked, or
punched or otherwise hurt by
someone within the past year?
If so by whom?


                                                For Clinical Use


Clients may have mental health issues that merit further assessment.        Yes       No

Mental Status:




Treatment Plan:
Referred for mental health assessment to:   Date
South Oaks Gambling Screen: Revised for adolescents (sogs-ra)


The 12 scored items for the SOGS-RA from winters, K.C., Stinchfiled R.D. and Fulkerson, J.
(1993a) are listed below

A. How often have you gone back another day to try and win back money you lost gambling?
      Every time       Most of the time      Some of the time       Never

B. When you were betting, have you ever told others you were winning money when you
weren’t?     Yes              No

C. Has your betting money ever caused any problems for you such as arguments with family and
friends, or problems at school or work?
                 Yes             No

D. Have you ever gambled more then you planned to?
               Yes           No

E. Has anyone criticized your betting or told you that you had a gambling problem weather you
thought it true or not?
                 Yes            No

F. Have you ever felt bad about the amount of money you bet or about what happens when you
bet money?
               Yes               No

G. Have you ever felt like you would like to stop betting but didn’t think you could?
               Yes              No

H. Have you ever hidden from family or friends any betting slips, IOU’s, lottery tickets, money
that you won or any signs of gambling?
                 Yes            No

I. Have you had money arguments with family or friends that centered on gambling?
               Yes          No

J. Have you borrowed money to bet and not paid it back?
                Yes           No

K. Have you ever skipped or been absent from school or work due to betting activities?
               Yes             No

L. Have you borrowed money or stolen something in order to bet or to cover gambling activities?
               Yes           No


Client Name                                               Date
                                     Mental Health Screening Form III


Instructions: In this program, we help people with all their problems, not just their addictions. This
commitment includes helping people with emotional problems. Our staff is ready to help you to deal with
any emotional problems you may have, but we can do this only if we are aware of the problems. Any
information you provide to us on this form will be kept in strict confidence. It will not be released to any
outside person or agency without your permission. If you do not know how to answer these questions, ask
the staff member giving you this form for guidance. Please note, each item refers to your entire life history,
not just your current situation, this is why each question begins- “have you ever…”


1) Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an
   emotional problem?
                                                    YES                          NO

2) Have you ever felt you needed help with your emotional problems, or have you had people tell you
   that you should get help for your emotional problems?
                                                    YES                      NO

3) Have you ever been advised to take medication for anxiety, depression, hearing voices, or for any other
   emotional problem?
                                                   YES                        NO

4) Have you ever been seen in psychiatric emergency room or been hospitalized for psychiatric reasons?

                                                       YES                         NO

5) Have you ever heard voices no one else could hear or seen objects or things which others could not
   see?
                                                   YES                         NO

6) a) Have you ever been depressed for weeks at a time, lost interest in pleasure in most activities, had
   trouble concentrating and making decisions, or thoughts about killing yourself?
                                                    YES                          NO
   b) Did you ever attempt to kill yourself?
                                                    YES                          NO

7) Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible
   event? For example, warfare, gang fights, fire, domestic violence, rape, incest, car accident, being shot
   or stabbed?
                                                     YES                         NO
8) Have you ever experienced any strong fears? For example, of heights, insects, animals, dirt, attending
   social events, being in a crowd, being alone, being in places where it may be hard to escape or get
   help?
                                                     YES                         NO

9) Have you ever given in to an aggressive urge or impulse, on more than one occasion, which resulted in
   serious harm to others or led to the destruction of property?
                                                       YES                    NO

10) Have you ever felt that people had something against you, without them necessarily saying so, or that
    someone or some group may be trying to influence your thoughts or behavior?

                                                       YES                         NO
11) Have you ever experienced any emotional problems associated with your sexual interests, you sexual
    activities, or your choice of sexual partner?
                                                  YES                        NO

12) Was there ever a period in your life when you spent a lot of time thinking and worrying about gaining
    weight, becoming fat, or controlling your eating? For example, by repeatedly dieting or fasting,
    engaging in much exercise to compensate for binge eating, taking enemas, or forcing yourself to throw
    up?
                                                      YES                        NO

13) Have you ever had a period of time when you were so full of energy and your ideas came very rapidly,
    when you talked nearly non-stop, when you moved quickly from one activity to another, when you
    needed little sleep, and believed you could do almost anything?

                                                       YES                        NO

14) Have you ever had spells or attacks when you suddenly felt anxious, frightened, uneasy to the extent
    that you began sweating, your heart began to beat rapidly, you were shaking or trembling, your
    stomach was upset, you felt dizzy or unsteady, as if you would faint?

                                                       YES                        NO

15) Have you ever had a persistent, lasting thought or impulse to do something over and over that caused
    you considerable distress and interfered with normal routine, work, or your social relations? Examples
    include repeatedly counting things, checking and rechecking things you had done, washing and re-
    washing you hands, praying, or maintaining a very rigid schedule of daily activities from which you
    could not deviate.

                                                       YES                        NO

16) Have you ever lost considerable sums of money through gambling or had problems at work, in school,
    with your family and friends as a result of your gambling?

                                                       YES                        NO

17) Have you ever been told by teachers, guidance counselors, or others that you have a special learning
    problem?
                                                       YES                        NO




Print Clients Name:                            Program to which client will be assigned:

Name of admissions counselor:                                            Date:

Reviewers comments:




Total Score:              (each yes = 1 pt.)
                               ASSESSING NICOTINE ADDICTION



     0-not a lot or N/A 1- A little bit 2- Somewhat 3- Quite a bit 4- Most or all of the time


                                                                                            0   1   2   3   4
I want a cigarette/nicotine within 5 minutes of waking up in the morning
I want a cigarette/nicotine just before I go to bed at night
I want a cigarette/nicotine after I eat a meal
I want a cigarette/nicotine with or after dessert or with a cup of coffee
I want a cigarette/nicotine when I see someone else lighting a cigarette or smoking
I want a cigarette/nicotine when I see an ad for cigarettes or nicotine
I want a cigarette/nicotine when I am late or when I am kept waiting
I want a cigarette/nicotine when I am angry or frightened
I want a cigarette/nicotine when I am criticized or make a mistake
I want a cigarette/nicotine when I am lonely
I want a cigarette/nicotine when I get bad news
I want a cigarette/nicotine when I watch TV
I want a cigarette/nicotine when I am driving a car
I want a cigarette/nicotine when I hear a telephone ring
I want a cigarette/nicotine when I have to do things I don’t like to do
I want a cigarette/nicotine when I am at a party
I want a cigarette/nicotine when I haven’t had one in 15 minutes
I want a cigarette/nicotine when I haven’t had one in 30 minutes
I want a cigarette/nicotine when I haven’t had one in an hour
I want a cigarette/nicotine when I want to be part of a crowd
I want a cigarette/nicotine when other people are smoking
I want a cigarette/nicotine when I am face with making a decision
I want a cigarette/nicotine just before an important meeting
I want a cigarette/nicotine when things don’t work out the way that I’d expect they would
I want a cigarette/nicotine when I get short tempered or irritable
I want a cigarette/nicotine when I start craving a cigarette
I want a cigarette/nicotine when I start having trouble concentrating
                                               Sex: _______________ Date of Birth: _____________
                                             County: ____________ Intake Date: ______________

INFECTIOUS DISEASE RISK ASSESSMENT FORM

Circle the answer for each question.

1.       yes     no        don’t know        Have you seen a doctor or other health care provider in the
         past 3 months?

2.       yes      no       don’t know        Do you live or have you lived on the street or in a shelter?

3.       yes      no       don’t know        Have you ever been in jail, prison or detention?

4.       yes    no       don’t know         Have you ever been in a long term care facility (nursing
         home,mental hospital, health hospital, or other hospital)?

5.       Where were you born?       _______________________________________

6.       yes      no      don’t know        In the past 3 years have you traveled/lived outside the U.S.
         (except for Canada, Australia, New Zealand, Japan, Western Europe or Great Britain)?

7.       Yrs/Mon_____________ How long have you lived in the U.S.?

8.       yes      no       don’t know        Are you a combat veteran?

9.        yes     no       don’t know        In the past 12 months have you had a tattoo, ear/body
piercing,                                              acupuncture or come into contact with someone
else’s blood?


10.      Within the last 30 days, have you had any of the following symptoms lasting for more than 2
         weeks?
____     Nausea                     ____     Fever
         ____     Productive cough ____      Coughing up blood
____     Brown tinged urine         ____     Jaundice (yellow skin or eyes)
____     Shortness of breath        ____     Losing weight without meaning to
____     Extreme fatigue            ____     Diarrhea (run) lasting more than a week
____     Lumps or swollen glands in neck or armpits
____   Drenching night sweats that were so bad you had to change clothes or sheets on your bed
____     Women only: Have you missed your last two periods?


11.      yes     no       don’t know       Have you ever been told you have TB? Has anybody you
         know or have lived with been diagnosed with TB in the past year?

12.     yes       no       don’t know        Have you ever had a positive skin test for TB? ( A test where
they gave you a shot in your forearm, and a few days later a hard lump appeared?

13.      yes      no       don’t know        Have you ever been treated for TB?

14.     Have you ever been told you have:
yes      no      don’t know        Hepatitis A?
yes      no      don’t know        Hepatitis B?
yes      no       don’t know        Hepatitis C?

15.      yes      no       don’t know        Have you ever used a needle to shoot drugs?

16.    yes        no       don’t know        Have you ever shared needles or syringes (“rigs”)to inject
drugs?

17.      yes      no       don’t know        Have you ever had a job that put you in danger of needle stick
injuries                                     or other types of blood contact?

18.      yes      no       don’t know        Do you use stimulants (cocaine/methamphetamines)?

19.      yes       no       don’t know       In the past 12 months, have you, or anyone you have had sex
with, had: syphilis, gonorrhea, herpes, chlamydia, nongonococcal urethritis, other sexually transmitted
diseases, or hepatitis?

To help find out if you are at increased risk for HIV, the virus known to cause AIDS, or Hepatitis C
(HCV), please take a minute to answer the following questions,

20.      yes      no       don’t know        Did you receive a blood transfusion before 1992?

21.      yes      no       don’t know        Have you received blood products produced before 1987
                                                    for clotting problems?
22.      yes       no      don’t know        Was your birth mother infected with Hepatitis C
virus during the time of your birth?

23.       yes     no       don’t know        Have you been, or are you currently, on long-term kidney
dialysis?

24.      yes      no       don’t know        Have you had unprotected sex with someone who has the
blood disease                                       hemophilia?

25.    yes        no       don’t know        Have you had unprotected sex with a person who injects
drugs?

26.     yes       no       don’t know        Have you had unprotected sex with a man who has sex with
other men?

27.      yes      no       don’t know        Have you had sex in exchange for money or drugs, or in order
to                                                  survive?

28.      yes     no      don’t know          Have you had sex with more than one person in the past 6
months? Any type of vaginal, rectal or oral contact without protection (condom or other barrier with or
without your consent)?

29.    yes      no       don’t know      Have you had sex or shared needles with a person who has
AIDS or who tested positive for AIDS/HIV disease or Hepatitis C?

30.      yes      no       don’t know        Have you ever injected drugs, even once?

31.     yes       no       don’t know        Have you ever been pricked by a needle or syringe that may
have been                                           infected with HIV or Hepatitis C?

32.     yes       no       don’t know        Have you ever had a drinking problem that required medical
care or                                      counseling?
33.     yes       no       don’t know        Have you ever been told or thought that you have a    drinking
problem?

    If you answered “no” to all the questions, you are not at increased risk for HIV / AIDS or Hepatitis C.
    If you answered “yes” or “don’t know” to any question, you may be at risk for AIDS, HIV or Hepatitis
     C.

The following questions are asked to help with treatment planning. It is not required that you answer them
to participate in assessment and/or treatment.

1.       Have you ever had a blood test for HIV antibody?               yes               no
         If “no” would you like a blood test?                           yes               no
         If “yes” have you been tested within the last 6 months?        yes               no

2.       Have you ever had a blood test for Hepatitis C virus ?         yes               no

3.      How would you judge your own risk for being infected with HIV (the AIDS virus)
I know I am infected _____            I think I am at NO risk _____ I think I am at high risk _____
        I am not sure what my risk is          _____ I think I am at low risk _____

4.      How would you judge your own risk for being infected with Hepatitis C?
I know I am infected _____             I think I am at NO risk _____ I think I am at high risk _____
        I am not sure what my risk is _____          I think I am at low risk _____
                           HEALTH HISTORY QUESTIONAIRE


  How would you describe your physical health at
                   this time?
Excellent         Good               Fair              Poor
Please explain:




How would you rate your mental health at this time?
Excellent         Good               Fair              Poor

Please explain:




Do you smoke or chew tabacco”           How much

Height            Weight             Weight one year ago

Are you overweight?                  If so how much?

Are you presently under a doctor’s care?          Have you been to a doctor within the last year?

When was your last physical?                  What is your physician’s name?


                                            EMOTIONAL STATUS

Have you ever been in counseling before? (Include psychiatric hospitalization, other residential programs,
out patient programs, etc.)

When                                          How long?

With whom                                     How long was that experience for?




                                     How have you been feeling these days?


When was your last physical fight?

Were you intoxicated/under the influence of drugs?

How has your appetite been recently?

How have you been sleeping recently?
Have you noticed any changes in your memory or concentration?

Describe:

PSYCHOLOGICAL HISTORY:

Have you ever been treated for a psychological, emotional, or behavioral problem by a psychiatrist,
psychologist, counselor, or other mental health person?
If yes, when, and by whom were you treated?



How do you handle stress?



Have you ever been treated for a mental illness      If so, when and where

Has anyone in your family ever had a serious mental/emotional problem?

Explain:




IN THE PAST THIRTY DAYS, CHECK ANY THAT APPLY TO YOU

           Suspicions of other people                Thoughts of killing/harming someone else
           Lack of sleep for more than               Muscle cramps
           3 consecutive day/nights                  Missed vein while injecting
           Ringing in ears                           Large bruises
           Thoughts of killing/harming your self     shared a needle with someone else


Were you abused emotionally, physically, and/or sexually as a child?

If yes, please explain:

If you checked “yes” to being a Victim of Rape/Incest/Sexual Abuse or Victim of other Physical
Abuse, was it reported to the police or Children’s Services Divisions (CDS)?
           YES             NO
*what was the outcome of the reporting, for example, did you receive counseling?



*Important: YES House staff are required to CSD all cases of child abuse

Do you have any questions or concerns about sexual matters that would like to talk about to a doctor or
counselor about?




List all present medical problems not mentioned above:
List all past medical problems not mentioned above:
                                YES House Honor Code
                   (Including) Property Damage Prevention Contract


  I am responsible for my own actions and future. To the best of my ability I will take ownership and be
            accountable for the outcomes of my decisions and I will learn from my mistakes.
I will try my best to control or improve my patterns of behavior by demonstrating
honesty and integrity in my actions and words.
I agree to be honest, kind, fair-minded, and respectful of others.
I understand that keeping secrets treatment is dangerous and hurts my recovery.
While I am at YES House, I share the responsibility with staff to keep myself safe
and confront any peer I know is using drugs, including nicotine and alcohol, or
who is bullying others. If that peer does not tell the group about the drug use,
keeping of contraband, or bullying, I accept the responsibility to tell the group,
including staff, what I know. This may be hard for me and will test my personal
commitment to recovery.
I agree as I begin my recovery to become socially responsible. I will begin
practicing this choice while I am in treatment through volunteer activities as they
present themselves.


I, _________________________________agree on this date
___________________
That if I commit property damage on any level, I will be charged a minimum of
$50 for the repair of said damage. In addition to the fee and probable legal
charge, I may be discharged from the YES House program and referred back to
parents, probation officers, or other adults that may be involved in my coming to
YES House.

                                                    _____                   ______
Client Signature    Date                            Parent/Guardian Signature               Date


Staff Signature                             Date
YES HOUSE                     404 NW 23Rd             Corvallis OR 97330
________________________________________________________________________
                                    ITEMS TO BRING
   Copy of insurance card or OHP card
   Phone numbers of emergency contact (PO's, doctor, etc.)
   $50 for damage deposit (refundable at end of treatment if no damage occurs)
   Medication should be "bubble packed”. YES House uses Safeway Pharmacy 450 SW 3rd
    Street Corvallis, and the phone # is 541-750-0166 (clients of Kaiser Permanente may have to
    use their local pharmacy).
   Client's Social Security Card PLUS original birth certificate and a picture ID (student body
    card, driver's license, passport)
   Proof of income (W-2 or 2 months check stubs) and guarantors social security number and
    ODL.
Appropriate clothing needs to be brought in at time of intake. YES House does not provide
clothing for clients or purchase clothing for clients. Purchase sweats & T-shirts for both boys
& girls in the men's department. All clothes need to be plain; no logos or designs, and
inexpensive. T-shirts are to be short or long sleeve, crew neck, and very loose fitting.
Sweatpants and shorts are to be fleece or cotton material, (no denim, pajamas, mesh or
shiny material).

*Clothing bundles can be purchased for $85.00 at Yes House. (Bundles do not
include socks, shoes or underwear.)
Clients need to bring:
 CLOTHING:                                          PERSONAL / HYGIENE CARE
   7-10 pairs of socks                              deodorant ( no aerosol cans)
   2 pair inexpensive comfortable shoes             shampoo / conditioner (no alcohol content)
  5-7 pair underwear --- girls must wear bras  comb / brush
   NO thong panties
 4-6 men's T-shirts (plain loose fitting)        sanitary supplies (females)
 3-4 sweats (elastic waistband                   disposable razors (1 use only per razor)
no more than 1" bigger than waist )       d       Clients may shave twice a week
 sweatshirts (can have a hood)                   shaving cream ( no alcohol content)
 inexpensive winter coat (wintertime)            toothbrush / toothpaste
 in summer cotton or fleece shorts; (no          postage stamps (optional)
   more than 2-3" above the knee)
 hats with no logos; worn outside only           $10 (or more) phone card
 umbrella or rain poncho (optional)              Bath soap/or shower gel
 bathrobe/slippers/flip-flops (optional)
 All personal items need to be marked with client's initials. YES House furnishes all bed linens,
               towels, hand soap and laundry soap. Clients do their own laundry.

MEDICATION / DOCTORS APPOINTMENTS:
It is the responsibility of parent / guardian to insure that client's prescriptions are filled and
refilled as needed. All medication will be checked in and out of the office where medications are
kept locked up. YES House DOES NOT provide transportation for any appointments that the
client may need while in treatment. It is the responsibility of the parent/guardian to make
appointments and take clients to and from appointments.

*****I agree that YES House will not be held responsible for any items that are lost or stolen.
Any contraband items, including clothing, brought into treatment after intake will be confiscated
and discarded.

____________________               ______        __________________                _______
Parent / Guardian Signature       Date            Client Signature                   Date



                          ITEMS NOT PERMITTED IN TREATMENT
The following list of clothing, personal items, etc. are prohibited while at YES House
CLOTHING /                      1. Any clothing with any insignias, logos, slogans, or pictures
PERSONAL ITEMS                     of rock bands, sports teams, alcohol, drugs, death,
                                   pornography, satanic, skulls, sexual, violent images or
                                   messages, or antisocial behaviors.
                                2. Bandanas or belts
                                3. Ropes or strings
                                4. Clothing with mesh, nylon or shiny material
                                5. Tank tops, spaghetti strap tops, belly shirts or sleeveless
                                   shirts, shorts more than 3" above knee or pants with a waist
                                   more than 1" larger than waist size
                                6. Clothing with pockets or zippers (sweatshirts can have a
                                   zipper)
                                7. Jewelry, including stud earrings or body piercing
                                8. Stuffed animals / magazines
                                9. Make-up
RECREATION                      1. Playing cards, poker chips or any gambling devices
                                2. TV, radio, computer, tape player, CD player, music tapes,
ITEMS                              compact disks, or cameras
                                3. Computer games, hand held game devices, hacky-sacks etc.
DRUG/                           1. Anything in aerosol cans
                                2. After shave, perfume or cologne
PARAPHERNALIA                   3. Alcohol, hair spray, or mouthwash.
                                4. Nail polish or polish remover
                                5. Markers, glue or bonding agent or whiteout
                                6. smoking or chewing tobacco, lighters, matches, or other
                                   smoking paraphernalia
                                7. Drugs or drug paraphernalia of any kind
SHARPS                          1. Mirrors, mirrored cases, compacts, etc.
                                2. Knives, metal rattail combs or other sharp objects
                                3. Pens, pencils, staples, tacks or needles
                                4. Wire coat hangers
OTHER                         1. Anything with an electrical cord, including electric razor,
                                 Haircutting equipment, curling irons, clothes iron, etc.
                              2. Food, sweets, candy, gum, or other snacks
                              3. Money
                              4. Posters or pictures for hanging on the wall

All clients will be searched at the time of admission and any time that they return from a
pass. Yes house reserves the right to do room searches and inspect all items brought for
clients to the treatment center. We also reserve the right to approve or deny any item(s)
for entry or usage at any time.

 YES House provides paper, envelopes, pencils, notebooks and binders
                             for clients.
                            YESHOUSE RESIDENT’S SUMMARY SHEET

Client Information                                                   Counselors:
Name of client                                                                    Date of admission

Address(city, state, zip code)                                                    Ethnic Identification

Sex              Date of Birth   Age   Marital status      Religious preference   Social security #


Family Guardian Information
Name of Parent(s)                                          Home Phone #           Work Phone #

Address:                                      City/State      Zip Code:

Legal Guardian (if any)                                    Home Phone #           Work Phone #

IN CASE OF EMERGENCY, CONTACT:                               PHONE #:




Medical Resources
Physician:

Address                                                    City/ State:           Phone #:

Dentist:

Address:                                                   City/State:            Phone #:

Insurance                                                  ID #:                  Group #:

Address:                                                   City/ State:           Phone #:

Referred to Yes House By:                                  Agency:


Community Resources (e.g. AOD Counselor, School Counselor, Probation Officer)
Community Resource:                        Contact Person:

Address:                                   City/ State:                   Zip Code:

Community Resource:                        Contact Person:

Address:                                   City/ State:                   Zip Code:
Comments




                                      YES HOUSE
                                  404 NW 23RD
                                  541-753-7801
                               CORVALLIS OR 97330

RESIDENT'S PHYSICAL DESCRIPTION:

NAME: _________________________ AGE: ____ DATE OF BIRTH: ________

SEX:   M ___ F ___    SOCIAL SECURITY NUMBER: _____ ____ ______

RACE: Caucasian ___ African / American ___ Hispanic ___ Native American ___
      Alaskan Indian ___ Chinese ___ Japanese ___ Other (Specify) _________

HEIGHT: _____ ' ____ "             WEIGHT: _______ LBS.

HAIR COLOR: Black ___ Brown ___ Blonde/Strawberry ___ Sandy ___
              Red/Auburn ___ Bald ___ Other ( __________________)

HAIR LENGTH: Short ___ Medium ___ Collar ___ Shoulder ___ Waist ___

HAIR STYLE:    Bald on top ___ All Bald ___ Crewcut/ Shaved ___ Braids ___
                 Part on left ___ Part Center ___ Part Right ___ Ponytail ___
                 Combed back ___ Wavy / Curly ___ Punk ___

BODY MARKS: Missing limb(s) _____________ Crippled Limb(s) ____________
             Needle Marks __________________ Scars _________________
             Tattoos _____________________ Injuries __________________
             Moles / Marks _______________        Other _________________

EYE COLOR:     Blue ___ Brown ___ Black ___ Green ___ Gray ___
                 Hazel Blue ___ Hazel Brown ___ Other (specify) ____________

GLASSES:         Yes ___ No ___     CONTACTS: Yes ___ No ___

COMPLEXION: Light ___ Medium ___ Dark ___ Freckles ___ Acne ___

FACIAL HAIR: None ___ Stubble ___ Mustache ___ Beard ___ Goatee ___
               Mustache and Beard ___ Other (specify) __________________

BUILD:           Slight ___ Average ___ Large ___ Muscular ___
                 Overweight ___ Other (specify) _________________________

TEETH:          Normal ___ Spaces ___ Chipped/Broken ___ Crooked ___
                Missing ___ Rotten ___ Braces ___ Retainer ___ Other _____
   SPEECH:           Normal ___ Accent ___ Slurred ___ Stutter ___ Foreign ___


      Impediment ___ Other (specify) ___________________

                    EMERGENCY PHONE NUMBER INFORMATION

If your child leaves treatment without completing the program due to running, away, leaving
against the advice of the treatment staff, etc., YES House will attempt to alert you at the
earliest possible moment through the telephone numbers you provide below.

Please list in order whom to contact first. Indicate if it is work, home, or cell phone number.

Contact Person             Relationship           Phone #                Type of #




In the event your child has violated a sufficient number of program rules, or violated a major
rule (such as bringing drugs into the facility) or jeopardizing other’s health, safety, or
welfare, the Program Manager may decide to terminate treatment. Any violent incident,
threat of violence, or property damage will be reported to the police.

If this should occur, YES House will telephone the parent/ guardian at the numbers listed
above and inform the parent/ guardian of the situation.



   Parent/ Guardian Signature        Date

***YES HOUSE ASSUMES NO RESPONSIBILITY FOR THE CLIENTS PERSONAL
POSSESIONS. CLIENTS ARE RESPONSIBLE FOR THEIR OWN CLOTHING AND
OTHER PERSONAL ITEMS. Clients are responsible for doing their own laundry. Staff will
not do it for them.

Any item left at YES House will be held for 30 days. During that time, clients and or parents/
guardians must make an appointment to pick up the items. After 30 days, YES House will dispose
of the items. Any contraband (tapes, CD’s, music players, jewelry, cigarettes, lighters, etc.)
brought into YES House will be immediately disposed of when confiscated.
                       Parent/ Guardian Signature                 Date




                     Telephone Calls to Clients and by Clients

                                       Incoming calls

When can I receive calls?

Administrative staff, counselors, or the weekend receptionist will answer the phone:

               Monday through Saturday                 8:30am-5: 30pm
               Sunday                                  12:00pm-6: 30pm

If you are available (not in class or group), and the administrative staff, counselors, or the
weekend receptionist can readily get you to the phone, you may be put on the phone to
take the call. If not, a message will be taken and given to you or your counselor for a
possible call back to an approved person.

Can Treatment Aids help me take an incoming phone call?

No. However, they may take messages for clients and give those messages to you or the
counselor on duty.


                                Outgoing Phone Calls
How can I make a phone call?

Phone calls may be made to anyone who has been approved by your counselor and is on
your phone list. You must first receive permission from your counselor each time you
want to make a phone call. When it is appropriate, your counselor will allow you to use
the phone in his/her office and monitor the call, or have the daytime administrative staff
supervise your phone call.

Telephone calls will be limited to a 5 minute maximum.

What about calls I need to make when my counselor isn’t working?

Your counselor can fill out a Client Services Request form requesting that another
counselor, the daytime administrative staff or the weekend receptionist to allow you to
make a phone call. The administrative staff and weekend receptionist WILL NOT be able
to allow you to make a phone call without the request form signed by your counselor.

Can any other staff person help me make phone calls?

NO! No one other than a counselor, administrative staff, or weekend receptionist can
assist with phone calls. Treatment Aides can not facilitate any phone calls!
                                            YES House
                                    Youth Entering Sobriety Rules

VIOLATION OF THE FOLLOWING RULES MAY RESULT IN IMMEDIATE DISCHARGE

1.     Alcohol, tobacco, or other drug use.

2.     Violence and/or threats of violence towards persons, property, or self.

3.     Destruction of property, program, personal, or other. This includes, but is not limited to:
       carving on furniture, writing or carving on walls, graffiti, putting holes in walls, intent to
       do harm, lighting matches or lighters. A damage deposit of $50.00 will be collected at
       intake and returned at discharge if not needed to cover costs of damage. Property damage
       always results in a police report ( charges/citation) and a minimum $50.00 fee.

4.     Sexual contact.

5.     Theft

6.     Refusal to follow treatment plan as agreed upon by the client and the counselor.

7.     Unauthorized leave from YES House.

8.     Breaking Federal, State, or County Laws.

9.     Violating another client’s confidentiality.

10.    Relationship building.

11.    Gambling.

12.    Helping another resident to break the rules.

13.    Enabling. Keeping secrets that result in the compromise of the program’s values
       affect another client’s personal safety, or threaten the safety of the YES House.

14.    Continued foul language, verbal abuse. (Your verbal content is a reflection of
       yourself and of your recovery.




_____________________________ ________                __________________________ _______
Client Signature              Date                    Parent/Guardian Signature Date


_____________________________ ________
Staff Completing admission   Date




                              The Treatment Team


Client Name: ____________________    Date of Admission: __________

The treatment team is more than the counseling staff and the support staff of
YES House. The treatment team is made up of other people that support you in
early recovery. This can be your parents, siblings, grandparents or other
relatives, a teacher or coach, a neighbor, probation officer, mental health
counselor or other counselors. In the spaces below please list those persons
you would like to see as a part of your treatment and recovery team.

            Name                    Relationship           Telephone Number




                              Teacher / Coach

                              Referral Source

                              Probation Officer
*****Insure a Release of Information is signed for each of the above named
persons for purposes of inviting them to a treatment and recovery team
meeting.



                   Academic Components for Yes House clients
         While enrolled at the YES House you will attend academic classes in math,
English, social studies, cultural awareness, and PE from approximately 8:00 AM to 12:15
PM, Monday through Friday. Within the first 5 days of enrollment you will complete a
math and a reading assessment to help establish your current skill levels in these two
academic areas. Information from your math assessment will help us determine
appropriate placement for you in our individualized math program. If your reading skills
are below grade level, teachers and assistants will make accommodations to help you
with reading materials, as needed.
         Typically, clients will fall into one of the following educational categories. Please
circle the number that best identifies your current academic status:
         1. For clients in the process of earning credits toward high school graduation
            your participation and successful completion of assignments will be reflected
            in seat time hours. Daily, each class equates to one hour of seat time; at the
            end of the week you can earn up to 38 seat time hours (may include some
            alternative and weekend classes). When you are discharged and return to
            your high school, seat time hours will be converted to credits (generally, 60-
            70 seat time hours in an academic area equals ½ credit). This category also
            applies to students working toward an alternative or modified diploma.
         2. For clients in the process of earning credits toward high school graduation
            and have brought course work or work is being sent from you high school,
            you will be excused from math and English classes and expected to use these
            times for completing your assignments. You will attend all other classes.
         3. For clients who are significantly deficient in high school credits and are
            considering taking the GED tests, you can take pre-tests and prepare for the
            five subtests while enrolled at the YES House. GED preparation work can be
            completed during the math and English classes. This category also applies to
            students considering alternative high school options such as Job Corps.
         4. If you have graduated from high school with a standard high school diploma
            or have earned your GED you are still required to participate in all classes.
            Regarding English and math, your first option is to work on treatment plans.
            If you do not actively do your treatment work you may continue to build your
            math and English skills.
         5. Clients still in middle school will complete the math and reading assessments
            and attend all classes.

       Your signature verifies you have read the above information and understand how
our academic program operates.
___________________________________                                     ____________________
Client signature                                                        Date

_____________________________________________________________           ___________________________________
Parent / Guardian’s signature                                           Date

____________________________________________________________            ___________________________________
YES House staff’s signature                                             Date


                                              YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name:                                                                    Date of Birth:


This is to authorize the TWO-WAY release of information regarding the above client.

Between:                      And:           Name:                                         Phone #:
YES House                                             Good Sam Emergency Care                       768-
5111
404 NW 23rd St                               Good Sam Urgent Care                          768-5021
Corvallis OR 97330                                  Safeway/3rd Street                            750-
0166
(541) 753-7801                               Benton Co. Health Dept                        766-6835
Fax: (541) 753-7805



PURPOSE OF RELEASE: To disclose information between parties, for the assessment and treatment of
emergency medical treatments.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

         My name and other personal identifying information
         Status in YES House
         Insurance/Billing Information
         To facilitate enrollment and receive medical results of visits.
I understand that the staff will maintain all medication in a locked cabinet. The above named client is
approved to self-administer medication under supervision of staff.

REVOCATION/EXPIRATION: This Authorization can be revoked by the under-signed at any time. The
cancellation will not affect any information that was already disclosed. Unless further limited by a date
stated here, _________, this Release of Information will automatically expire after a period of 60 days from
discharge. I have the right to receive a copy of this Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

                                                                                 ___ / ___ / ______

Signature of Client                                                              Date

                                                                                 ___ / ___ / _____
Signature of Parent / Guardian                                                  Date

                                                                                ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information              Date




NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION
The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).
You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom it pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                             YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name:                                                                    Date of Birth:


This is to authorize the TWO-WAY release of information regarding the above client.

Between:                      And:           Name:                                        Phone #:
YES House                                             Children’s Medical Project
404 NW 23rd St                               Benton Co. AFS
Corvallis OR 97330                                  CARDVA
(541) 753-7801
Fax: (541) 753-7805



PURPOSE OF RELEASE: To disclose information between parties for enrollment in above programs.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

       My name and other personal identifying information
       Status in YES House
_____ To facilitate enrollment and receive benefits of program.

REVOCATION/EXPIRATION: This Authorization can be revoked by the under-signed at any time. The
cancellation will not affect any information that was already disclosed. Unless further limited by a date
stated here, _________, this Release of Information will automatically expire after a period of 60 days from
discharge. I have the right to receive a copy of this Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

                                                                                 ___ / ___ / ______

Signature of Client                                                              Date

                                                                                 ___ / ___ / _____
Signature of Parent / Guardian                                                   Date

                                                                                 ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION
The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).
You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom it pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.




                                             YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name: _______________________________                                             Date of Birth:
 __________

This is to authorize the TWO-WAY release of information regarding the above client.

Between:                   And:        Name:                            Relationship:
       Phone:
YES House                                                               Outpatient counselor

404 NW 23rd St                                                          Mental Health Person

Corvallis OR 97330                                                      Insurance Company

(541) 753-7801                                                          Sterling Laboratory

Fax: (541) 753-7805


PURPOSE OF RELEASE: To disclose information between parties, for the assessment and treatment of
alcohol and other drug addictions.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

        Name and other personal identifying information
______ Initial Assessment                               ______ Treatment Summary
______ Intake Summary/Diagnostic Impressions            ______ Referral Information
______ Treatment Plan                                   ______ Legal History Information
______ Urinalysis Results                               ______ Family History
______ Status Report/Treatment Plan Review              ______ Mental Health Assessment
______ Progress Notes                                   ______ Discharge Plan
______ Insurance/Billing Information                    ______ Other:
____________________________________

REVOCATION/EXPIRATION: This Authorization can be revoked by the under-signed at any time. The
cancellation will not affect any information that was already disclosed. Unless further limited by a date
stated here, _________, this Release of Information will automatically expire after a period of 60 days from
discharge. I have the right to receive a copy of this Release of Information upon my request.
 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                        ___ / ___ / ______

Signature of Client                                                             Date

_________________________________________________________                       ___ / ___ / _____
Signature of Parent / Guardian                                                  Date

________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________


NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                             YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name: _______________________________                                             Date of Birth:
 __________

This is to authorize the TWO-WAY release of information regarding the above client.

Between:                      And:           Name:                      Relationship:
       Phone:
YES House                                                               School of Origin

404 NW 23rd St                                                          Corvallis School District

Corvallis OR 97330                           Ruth Johns                 Associated Specialist W / CSD

 (541) 753-7801
Fax: (541) 753-7805


PURPOSE OF RELEASE: To disclose information between parties, for the assessment and treatment of
alcohol and other drug addictions.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

      My name and other personal identifying information
      Status in YES House
____ Date of enrollment, transcripts, IEP / 504 plan recommendations, other academic
recommendations.

REVOCATION/EXPIRATION: This Authorization can be revoked by the under-signed at any time. The
cancellation will not affect any information that was already disclosed. Unless further limited by a date
stated here, _________, this Release of Information will automatically expire after a period of 60 days from
discharge. I have the right to receive a copy of this Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                         ___ / ___ / ______

Signature of Client                                                              Date

_________________________________________________________                        ___ / ___ / _____
Signature of Parent / Guardian                                                   Date
________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________



NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                             YES House
                      Authorization For Two-Way Release Of Client Information

                                     Family & Friends
 Client Name: _______________________________                                             Date of Birth:
 __________

This is to authorize the TWO-WAY release of information regarding the above client.

Between:                      And:           Name:                      Relationship:              Phone:

YES House

404 NW 23rd St

Corvallis OR 97330

541) 753-7801

Fax: (541) 753-7805



PURPOSE OF RELEASE: To enhance achievement of treatment goals and support network
communications.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

______ Status in treatment                           ______ Phone calls and information learned in
groups

REVOCATION/EXPIRATION: This Authorization can be revoked by the under-signed at any time. The
cancellation will not affect any information that was already disclosed. Unless further limited by a date
stated here, _________, this Release of Information will automatically expire after a period of 60 days from
discharge. I have the right to receive a copy of this Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                         ___ / ___ / ______

Signature of Client                                                              Date

_________________________________________________________                        ___ / ___ / _____
Signature of Parent / Guardian                                                   Date
________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________



NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                            YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name: _______________________________                                          Date of Birth:
 __________

This is to authorize the TWO-WAY release of information regarding the above client.

Between:                     And:          Name:                     Relationship:
       Phone:
YES House                                                            Probation Officer

404 NW 23rd St                                                       County Drug Court

Corvallis OR 97330
(541) 753-7801
Fax: (541) 753-7805


PURPOSE OF RELEASE: To disclose information between parties, planning and coordination of
treatment services.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

      Name and other personal identifying information
____ Initial Assessment                         ____ Treatment Summary
____ Intake Summary/Diagnostic Impressions             ____ Referral Information
____ Treatment Plan                                    ____ Legal History Information
____ Urinalysis Results                         ____ Family History
____ Status Report/Treatment Plan Review               ____ Mental Health Assessment
____ Progress Notes                                    ____ Discharge Plan
____ Other:
REVOCATION/EXPIRATION: This Authorization can not be revoked by the under-signed at any time.
Unless further limited by a date stated here, _________, this Release of Information will automatically
expire when probation status changes. I have the right to receive a copy of this Release of Information
upon my request. The cancellation will not affect any information that was already disclosed.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                      ___ / ___ / ______

Signature of Client                                                           Date
_________________________________________________________                       ___ / ___ / _____
Signature of Parent / Guardian                                                  Date

________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________



NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                             YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name:                                                                   Date of Birth:


This is to authorize the TWO-WAY release of information regarding the above client.

Between:                  And:              Name:
         _________________________
YES House                                   Relationship:                       parent(s) /guardian
404 NW 23rd St                              Address:
         _________________________
Corvallis OR 97330                          City, State, ZIP:
         _________________________
(541) 753-7801                              Home Phone #:
         _________________________
Fax: (541) 753-7805                         Work #:
         _________________________


PURPOSE OF RELEASE: To disclose information between parties, for the assessment and treatment of
alcohol and other drug addictions.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):
______ Initial Assessment                            ______ Treatment Summary
______ Intake Summary/Diagnostic Impressions         ______ Referral Information
______ Treatment Plan                        ______ Legal History Information
______ Urinalysis Results                            ______ Family History
______ Status Report/Treatment Plan Review           ______ Mental Health Assessment
______ Progress Notes                                ______ Discharge Plan
______ Insurance/Billing Information                 ______ Other:
____________________________________

REVOCATION/EXPIRATION: This Authorization is subject to revocation by the under-signed at any
time except to the extent that information has already been disclosed based on authorization contained
herein. Unless further limited by a date stated here, _________, this Release of Information will
automatically expire after a period of 60 days from discharge. I have the right to receive a copy of this
Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                        ___ / ___ / ______

Signature of Client                                                             Date

_________________________________________________________                       ___ / ___ / _____
Signature of Parent / Guardian                                                  Date

________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________

NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                             YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name:                                                                   Date of Birth:


This is to authorize the TWO-WAY release of information regarding the above client.

Between:                  And:              Name:
         ______________________
YES House                                   Relationship:                       Doctor
404 NW 23rd St                              Address:
         ______________________
Corvallis OR 97330                          City, State, ZIP:
         _______________________
(541) 753-7801                              PHONE #:
         _______________________
Fax: (541) 753-7805                         FAX #:
         _______________________


PURPOSE OF RELEASE: To disclose information between parties, for the assessment and treatment of
medical needs

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

X______ Other: Medical information as needed for TX
REVOCATION/EXPIRATION: This Authorization is subject to revocation by the under-signed at any
time except to the extent that information has already been disclosed based on authorization contained
herein. Unless further limited by a date stated here, _________, this Release of Information will
automatically expire after a period of 60 days from discharge. I have the right to receive a copy of this
Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                        ___ / ___ / ______

Signature of Client                                                             Date

_________________________________________________________                       ___ / ___ / _____
Signature of Parent / Guardian                                                  Date

________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION
The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws (42 CFR Part 2, ORS 192.500, ORS 179.505).
You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                             YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name:                                                                    Date of Birth:


This is to authorize the TWO-WAY release of information regarding the above client.

Between:                      And:           Name:                               Corvallis Police
Department
YES House                                    Relationship:
404 NW 23rd St                               Address:                            180 NW 5th
Corvallis OR 97330                           City, State, ZIP:                   Corvallis OR 97330

(541) 753-7801                               PHONE #:                            757-6975
Fax: (541) 753-7805                          FAX #:                              754-1722


PURPOSE OF RELEASE: To disclose information between parties, to report runaway status from YES
House.


SPECIFIC INFORMATION TO BE RELEASED:

         Personal Identification information including a minimum description of self, clothing, time of
         runaway, home address, parent's name, probation officer name, name of referral agency.

         X ____ client initial       X____ parent/ guardian initial



REVOCATION/EXPIRATION: This Authorization is subject to revocation by the under-signed at any
time except to the extent that information has already been disclosed based on authorization contained
herein. Unless further limited by a date stated here, completion of treatment or termination this Release
of Information will automatically expire after a period of 30 days from discharge. I have the right to
receive a copy of this Release of Information upon my request.

*** By signing this release, YES House has my/our permission to act as guardian in the event that the
client is reported as a "runaway" and we authorize local authorities to detain client until
parent/guardian can respond.***

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                         ___ / ___ / ______

Signature of Client                                                              Date

_________________________________________________________                        ___ / ___ / _____
Signature of Parent / Guardian                                                   Date
________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________

NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
YES House Alternative School
404 NW 23rd
(mailing) 518 SW 3rd
Corvallis, Oregon 97333
(541) 753-7801
                      REQUEST FOR TRANSFER
       OF EDUCATIONAL RECORDS AND WITHDRAWAL GRADES

To:   School:
      Address:
      City:
      Telephone:                             FAX:
      Counselor:

Please forward all educational records and withdrawal grades for the
following
student to:             YES House Alternative School
                        518 SW 3rd
                        Corvallis, Oregon 97333
                        FAX: (541) 753-7805

Re:   Student:                              DOB:               SS#:

Parents/Guardians Names:

Please include the following:
Withdrawal Grades: Grades earned up to time of withdrawal from school.
Progress Reports: Transcripts of grades and courses taken, competencies
of ability, and records of health.
Behavioral Records: Include psychological tests, personality evaluations,
records of conversations, and any written transcripts of incidents relating
specifically to student behavior.
Individualized Education Plans: Include any progress toward goals and
current objectives. Include and special education instructions.
This request serves to advise you that for State of Oregon records this
student,
                                     , is being carried on the academic
roll of the YES House Alternative School in Corvallis, Oregon. Be advised
that under all circumstances the student mentioned above will be
documented on our academic records as attending the YES House
Alternative School and may no longer be carried as an active student
with your school.
School student will be attending following treatment?


Name of School          City                    County          State



Student Signature              Date        Parent/Guardian Signature
Date
                                            YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name: _______________________________                                           Date of Birth:
 __________

This is to authorize the TWO-WAY release of information regarding the above client.

Between:                  And:        Name:                           Relationship:
YES House                                                             Jackson Street Youth Shelter
404 NW 23rd St                                                        500 Jackson Street
Corvallis OR 97330                                                    Corvallis, OR 97330
(541) 753-7801                                                        (541) 754-2404
Fax: (541) 753-7805                                                   Fax: (541) 754-2405


PURPOSE OF RELEASE: To disclose information between parties, for the assessment and treatment of
alcohol and other drug addictions.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

        Name and other personal identifying information
______ Initial Assessment                                 ______ Treatment Summary
______ Intake Summary/Diagnostic Impressions              ______ Referral Information
______ Treatment Plan                             ______ Legal History Information
______ Urinalysis Results                                 ______ Family History
______ Status Report/Treatment Plan Review                ______ Mental Health Assessment
______ Progress Notes                                     ______ Discharge Plan
______ Insurance/Billing Information                      ______ Other:
____________________________________

REVOCATION/EXPIRATION: This Authorization can be revoked by the under-signed at any time. The
cancellation will not affect any information that was already disclosed. Unless further limited by a date
stated here, _________, this Release of Information will automatically expire after a period of 180 days
from the date signed. I have the right to receive a copy of this Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                       ___ / ___ / ______

Signature of Client                                                            Date

_________________________________________________________                      ___ / ___ / _____
Signature of Parent / Guardian                                                 Date

________________________________________________________                       ___ / ___ / ______
Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________


NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                            YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name: _______________________________                                           Date of Birth:
 __________

This is to authorize the TWO-WAY release of information regarding the above client.

Between:                  And:        Name:                           Relationship:
YES House                                                             Job Corps
404 NW 23rd St                                                        3865 Wolverine St., Bldg. E, #6
Corvallis OR 97330                                                    (503) 589-4066
(541) 753-7801                                                        Fax: (503) 589-4068
Fax: (541) 753-7805


PURPOSE OF RELEASE: To disclose information between parties, for the assessment and treatment of
alcohol and other drug addictions.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

        Name and other personal identifying information
______ Initial Assessment                                 ______ Treatment Summary
______ Intake Summary/Diagnostic Impressions              ______ Referral Information
______ Treatment Plan                             ______ Legal History Information
______ Urinalysis Results                                 ______ Family History
______ Status Report/Treatment Plan Review                ______ Mental Health Assessment
______ Progress Notes                                     ______ Discharge Plan
______ Insurance/Billing Information                      ______ Other:
____________________________________

REVOCATION/EXPIRATION: This Authorization can be revoked by the under-signed at any time. The
cancellation will not affect any information that was already disclosed. Unless further limited by a date
stated here, _________, this Release of Information will automatically expire after a period of 180 days
from the date signed. I have the right to receive a copy of this Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                       ___ / ___ / ______

Signature of Client                                                            Date

_________________________________________________________                      ___ / ___ / _____
Signature of Parent / Guardian                                                 Date
________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________


NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                            YES House
                      Authorization For Two-Way Release Of Client Information

 Client Name: _______________________________                                           Date of Birth:
 __________

This is to authorize the TWO-WAY release of information regarding the above client.

Between:                  And:        Name:                           Relationship:
YES House                                                             Rimrock Trails
404 NW 23rd St                                                        1333 9th Street; Prineville, OR
97354
Corvallis OR 97330                                                    (541) 447-2631
(541) 753-7801                                                        Fax: (541) 447-2616
Fax: (541) 753-7805


PURPOSE OF RELEASE: To disclose information between parties, for the assessment and treatment of
alcohol and other drug addictions.

SPECIFIC INFORMATION TO BE RELEASED (client’s initials to approve release):

        Name and other personal identifying information
______ Initial Assessment                                 ______ Treatment Summary
______ Intake Summary/Diagnostic Impressions              ______ Referral Information
______ Treatment Plan                             ______ Legal History Information
______ Urinalysis Results                                 ______ Family History
______ Status Report/Treatment Plan Review                ______ Mental Health Assessment
______ Progress Notes                                     ______ Discharge Plan
______ Insurance/Billing Information                      ______ Other:
____________________________________

REVOCATION/EXPIRATION: This Authorization can be revoked by the under-signed at any time. The
cancellation will not affect any information that was already disclosed. Unless further limited by a date
stated here, _________, this Release of Information will automatically expire after a period of 180 days
from the date signed. I have the right to receive a copy of this Release of Information upon my request.

 SIGNATURES CERTIFYING APPROVAL FOR TWO-WAY RELEASE OF INFORMATION:

________________________________________________________                       ___ / ___ / ______

Signature of Client                                                            Date

_________________________________________________________                      ___ / ___ / _____
Signature of Parent / Guardian                                                 Date
________________________________________________________                        ___ / ___ / ______

Signature of Witness or Agent Authorized for Releasing Information Date
______________________________________________________________________________________
_____________


NOTICE TO ORGANIZATION OR INDIVIDUAL RECEIVING INFORMATION

The information has been disclosed to you from our records whose confidentiality is protected by state and
federal laws
(42 CFR Part 2, ORS 192.500, ORS 179.505).

You are prohibited from making any further disclosure of this information without the specific written
consent of the person to whom pertains or as otherwise permitted by the laws and regulations. A general
authorization for the release of medical or other information is not sufficient for the purpose.
                                              Yes House
                                                Safety Plan
Client Name                          Date
In the past, what have been the circumstances and cause of your self-harm (running away, cutting, suicide)
thoughts, plans, and actions?
Running Away:                         Cutting:                           Suicide:




At the present time and throughout your treatment at Yes House, what do you foresee to be the possible
circumstances and causes of self-harm thoughts, plans, and actions?
Running Away:                       Cutting:                           Suicide:




What things can you think of that would be alternatives and preventions to self-harm thoughts or plan:
1.

2.

3.

I,                                     , agree to do the following things as alternatives to self- harm.
     1. I will notify a staff person immediately when I am experiencing these thoughts.
     2. I will give myself 24 hours before taking any action.
     3. I will, with my counselor or staff person, notify my parents or an adult from my support
        system, of my thoughts or plans about self-harm prior to taking any action
     4.


Client Signature:                                                 Date

								
To top