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THE CONNECTION INC., MERIDEN AIC 174 State Street. Meriden, CT 06450

0 DEFENDANT'S

EXHIBIT

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Discharge Report
Date: 7/31/07 Client Name: Komisatjevsky, Joshua
Date of Admission: 3127/07 To:Abigail Cintron. 95 Scovill Street, Waterbury, Ct Successful Discharge Assessments Completed: LSJ-R _19_ (Pre-triallParole only) _ Unsuccessful Discharge _X __ Group Track: Cognitive Skills _X_ Employment Services __ Substance Abuse Group _X_

DOB: 8/1011980
Date of Discharge: 7124/07

ASUS _18_ (Pre-triaIlParole only) SAI __ (Pre-trial/Parole only)
Group Track: Cognitive Skills __

# of days scheduled to attend __ # of days attended Reason for absence (5) __ Employment Services __ # of days scheduled to attend __ # of days attended Reason for absence (s) -:--:--:- _ --:_ Substance Abuse Group _ X_ # of days scheduled to attend __ # of days attended Reason for absence (s) _Completed Level of Participation: Excellent __ X___ Good # of sessions __ Fair Weekly

_
on 5121/07

Needs Improvement #- unexcused absences 13

_ _

Individ ual Contact:

Urinalysis: Dates and Results 413""neg, 4123=neg, 5/10=beg, 5121=neg, 6n=neg, 6/28=neg Commonity Service: Employment Status: Scbool Status: Special Conditions: Special Parole to begin
00

# of hours assigned Currently employed _X__

# of hours completed Actively seeking employment

_ _ _

8/2/07

Discbarg~ Plan: Mr. Komisarjevsky was referred to the Meriden AIC by his Parole Officer Abiga~1 Ci~tron. He waS re.ferred with tbe:following set conditions: I) obtain/maintain fuD time employment. 2) attend the substaiJ.u abuse group (freating Alcohol Dependence). 3) attend the cognitive skills group (Reasoning & Rehabilitation 2). 4) Render random urinesfor testing. Mr. Komisarjevsky began tbe TAD group on 4/9/07 and successfuUy completed the group OD salto7. He only missed 2 sessions ofTAD~ Sn/07 was cancelled and Mr. Komisarjevsky was absent on 5/9/07. Mr_ Komlsarjevsky self reported that he chaired the Tuesday evening Cocaine Anonymous meeting on the grounds oUbe Institute of Living. Mr. Komisarjevsky was on tbe waiting list for the next R & R group to begin based on the fact tbat he had successfully completed the TAD group. Mr. Komisarjevsky met weekly with this counseler, The individual sessions focused on assisting tbe client in maintaining bis sobriety, referring bim to appropriate resources in the community in response to his desire to obtain custody of his daugbter (who was living with him and his parents)and managing his conflicted relationsbip with his ex-girlfriend who was also the mother of his daughter. Mr. Komisarjevsky was employed through Hartford Restoration Services Inc. He provided pay stubs for proof of employment.

K13017-0001

On 7124/07 the AIC was notified through the court tbat Mr. Komisarjevsky was arrested with new charges and therefore, is being unsuccessfully discharged from the Meriden Ale. Case Manager . .

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K13017 -0002

Chronological Notes

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K13017 -0003

Chronological Notes

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K13017-0007

Chronological Notes

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K13017 -0008

Chronological Notes
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K13017 -0009

Chronological Notes

CLIENT NAME:
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K13017-0010

AlC SIX PART FILE SET UP

Section • • Section • • • • • • • • •

,I

Six Part File Check list . Chronological Notes (on top)

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Referral Form (on top) Intake Form Statistical Form (optional) Transfer Form Facility Rules HIPPAForm PhotoNideo Consent Form Judicial Pboto Release Form Release of Information Form

Section ill • Assessments • ISP Forms

* (pre-triaUparole

only)

Section IV •. Group Reports Section • • • • Section • • • • V* U rineJBreathBlyzer Consent Form Urine Log Urine request/results Community Service Forms VI Court Letters Monthly Reports Discharge Reports Miscellaneous (pay stubs, doctor's nate.job search information

etc.) clients

*Probation Clients will sign all forms with the exception Section V urine forms, Probation will not be provided with an ISP.

K13017-0011

ALC CLIENT [NTAKE REPORT

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.Physical Li~ns

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Revised 10105 K13017-0012

Ale CLIENT STATISTICS SHEET

Offense Code:

A Felony _

B Felony _

C Felony __

/

D Felony __

A Misdemeanor B Misdemeanor C Misdemeanor D Misdemeanor __ Unclassified Felony _ Unclassified Misdemeanor __ Risk Level: Surveillance 35 and above

Medium
Status:

2-24

./

High 25-34 ~ Sex Offender __

Pre-Trial Bail

---_ _

Pre-Trial Family
Probation --::

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Personal Data:

Parole
Electronic Monitoring:

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Yes

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No ----:::.--Gender __ /' M .F Race Native American African American __ Hispanic __fisian _~_ C. Caucasian Other

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K13017 -0013

ALTERNATIVE INCARCERATION CENTER PROGRAM PARTICIPATION CONTRACT

Ale Services
Substance Abuse Groups - meet (2) two times per week for 90 minutes. Cognitive Skills Groups - meet (2) two times per week for 2 hours. Employment Services Groups - meet (4) four consecutive days for 2 to 3 hours.

Upon completion of employment skills you will mgraduate" to active job finding and report to your Employment Specialist until a job is secured. During your employment group you may participate in community service, so staff may observe and give feedback on your work skills. Substance use testing -If ordered by the court, probation or parole, you must submit to random drug testing either through a urine sample or breathalyzer. _Pre.-trial partlcipants- Prior to beginning services, you will take part in an assessment process which will determine what services are most appropriate for you and how often you will report to the program. You will also be placed in services that are ordered by the Court. Prior to beginning services, you will take part in a brief overview of the cfasses(s) and/or services you will be participating. _Family Relations participants - Your Family Relations Officer has referred you to the AIC to receive service(s) based on their assessment(s). Prior to beginning services, you will take part in a brief overview of the classes(s) andlor services you will be participating. _Probation Participants· • Your Probation Officer has referred you to the Ale to receive service(s) based ir assessment Prior to beginning s. rvices, you will take part in a brief overview of the classes(s) and/or e ces you will be participating. arale Participants- Prior to beginning services, you will take part in an assessment process which will determine what services are most appropriate for you and how often you will report-to the program. You will also be placed in services that are ordered by your Parole Officer. Prior to beginning services, you will take part in a brief overview of the classes(s) and/or services you will be participating.

_)

1. Class Time: Classes will start and end on time. Participants are expected to be on time. Participants may not leave early unless agreed upon with the group facilitator prior to group.
2.
Attendance: Participants are expected to attend all scheduled individual and group activities for example: case management, group interventions, check-in's, and community service. If you are going to miss a scheduled appointment or service you must call the AIC prior to your scheduled appointment. If you have missed an appointment due to an emergency, you must contact the AIC within 24 hours. The Court, Probation and/or Parole Officer will be notified of all absences (excused and non-excused). To ensure accurate reporting, you must sign in when you arrive at the Ale and sign out prior to leaving. FOR GROUP PARTICIPATION

EXPECTATIONS o []

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All class participants must actively participate in class. This requires being awake 'and alert. One person speaks at a time out of respect for themselves and others. 00 nottouch Qijler'particjpants or facilitators without permission. SWearing or yelling other than in the course of an appropriate role-play is not allowed. Do' not discuss other participants, situations, or stories outside of group. Participants are asked to respect the rights of fellow participants to confidentiality. What is sald in class should stay in class. Participants are asked not to talk about other participants outside of class. All class participants will meet 1:1 with their group facilitator two times during the course of each group cycle. Your group facilitator will schedule this meeting with you outside of group time. assignments. You must bring completed homework

Homework: Participants will have homework to the next class as assigned.

Revised 12/07/06

K13017-0014

4.

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Classes will be videotaped and 1:1 sessions will be audio taped only for the purposes of supervision and training of AIC staff. Tapes are used to help ensure the quality of services you receive; they will not be used against participants. Community Service may be a part of your service plan. Community Service crews participate in a wide variety of work: in the local communities, under the guidance of a Community Service Supervisor/Coordinator. Crews work on projects such as construction, park/forest maintenance, and painting, with jobs varying from day to day. Giving something back to the community can have a positive impact on your life and the community in which you live. It is important to be on time for community service projects. \ Drugs/Alcohol: To increase the likelihood of success in the program, participants are expected to report to the Ale in a drug/alcohol free state. AIC staff who suspect that a participant has come to the AIC under the influence of drugs and/or alcohol will ask the client to leave the facility. This will be reported to the CourtlProbation or Parole Officer. Please report any prescribed medication you are taking or when it is prescribed.

5.

6.

7. Threats of Harm to Self or Others: All threats of harm to self or others will be taken seriously and will result in immediate action with notification to the proper authority i.e. law enforcement, Probation and Court. Any acts of violence while in the program will be immediately reported to law enforcement and the Court, Probation and/or Parole. Additionally, AIC staff will report to the appropriate authorities any current criminal activity and awareness of child abuse. 8. Weapons: Parficlpants may not carry weapons of any kind. If a participant is found to be in possession of weapon law enforcement, Court, Probation and/or Parole personnel will be immediately notified. '~) 9. Pat searches: To ensure the safety of all random pat searches may be conducted. 10. Cell Phones/Pagers: For the class to function well it is important to reduce distractions. Upon entering the AtC participants must tum off all cell phones, pagers, radios, and other electronic equipment (not related to their health) for the duration of the class. Vibrating settings on pagers and cell phones are not allowed. Text messaging and earphones are not allowed. 11. Clothing/Gang Colors/Hats: Participants may not wear gang clothing or paraphernalia. Participants may not wear hats or sunglasses during class. 12. Disruptive Behavior: Participants are expected to behave respectfully to Ale staff, other particip~nts, and any others in the building. Participants must cooperate with class facilitators and contribute to discussions and activities. Disruptive behavior will not be tolerated. If a participant is disi't!ptive during a class, slhe may be asked to leave. 13. Notification: So we may contact you, you must notify staff of any changes in address, phone or employment within 24 hours.

Signature of Parent or Guardian of Minor (if applicable)

Date

Revised 12107/06

K13017-0015

THE CONNECTION, INCORPORATED MERIDENAIC
NOTICE OF PRIVACY PRACTICES
Effective Date April 14, 2003 BE USED AND DISCLOSED

THIS NOTICE DESCRIBES HOW MEDICAUHEALm INFORMATION ABOUT YOU MAY AND HOW YOU CANGET ACCESS TO TInS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by Jaw to maintain the privacy of your heaJth information; to provide you this detailed Notice of our legal duties and privacy practices relating to your health information; and to abide by the terms of the Notice that are currently in effect.

L USES AND DISCLOSURES FOR TREATMENT.
OPERATIONS

PAYMENT AND REALm

CARE

The following lists various ways in which we may use or disclose your health information for purposes of

treatment, payment and health care operations.
For Treatment. We will use and disclose your health information in providing you with treatment and services and coordinating your care and may disclose information to other providers involved in your care. Your health information may be used by doctors involved in your care and by other clinicians as welJ as by physical therapists, pharmacists, suppliers of medical equipment or other persons involved in your care. For example, we will contact your physician to discuss your plan of care.

For Payment. We may use and disclose your health information for billing and payment purposes. We may disclose your health information to your representative, or to an insurance or managed care company. Medicare, Medicaid or another third party payer. For example, we may contact Medicare or your health plan to confirm your coverage or to request prior approval for services that will be provided to you.
For Health Care Operations. We may use and disclose your health information as necessary for health care operations, such as management, personnel evaluation, education and training and to monitor our quality of care. We may disclose your health information to another entity with which you have or had a relationship if that entity requests your infonnation for certain of its health care operations or health care fraud and abuse detection Or compliance activities. For example, health information of many patients may be combined and analyzed for purposes such as evaluating and improving quality of care and planning for services.

n.

SPECIFIC

USES AND DISCLOSURES OF YOUR REALm

INFORMATION

The following lists various ways in which we may use or disclose your health information. Individuals Involved in Your Care or Payment fOT Your Care. Unless you object, we may disclose health information about you to family member, close personal friend or other person you identify, including clergy, who is involved in your care.

a

Emergencies. situations.

We may use or disclose your health information

as necessary in emergency treatment

As Required By Law. We may use or disclose your health information when required by law to do so.

)

Business Associates. We may disclose your protected health information to a contractor or business associate who needs the information to perform services for the Provider. Our business associates are committed to preserving tile confidentiality of this information.

P. 1 of 5
K13017-0016

Public Health Activities. We may disclose your health information for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability; reporting child abuse or neglect or reporting births and deaths. Reporting Victims of Abuse, Neglect·or Domestic Violence. Ifwe believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your health information to notify a government authority, if authorized by la~ or if you agree to jhe report. \ Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by Jaw, such as audits, investigations, inspections and licensure actions or for activities involving government oversight of the health care system. To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person, we may use or disclose health information, limiting disclosures to sonieone able to help lessen or prevent the threatened harm. Judicial and Administrative Proceedings. We may disclose your health information in response to a

court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process; efforts must be made to contact you about the request or to obtain an order or agreement protecting the information,
Law Enforcement We may disclose your health information for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes. Research. We may use or disclose your health information for research purposes if the privacy aspects of the research have been reviewed and approved, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure. Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your health information to a coroner, medical examiner, and funeral director or, if you are an orgB:Jl onor, to an organization involved in the donation of organs and tissue. d Disaster Relief. We may disclose health information about you to a disaster relief organization. Military, Veterans and other Specific Government Functions. If you are a member of the armed forces, we may use and disclose your health lnformation as required by military command authorities. We may disclose health information for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.

..

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to workers' compensation

Workers' Compensation.

We may use or disclose your health information to comply with laws relating or ~imllar programs.

InmateslLawEnforcement Custody .. If you are under the custody of a law enforcement officiaJo~'a correctional institution, we may disclose your health Information to the institution or official fot certain purposes including the health and safety of you and others. .. Fundraising Activities. We may use certain limited information to contact you in an effort to raise funds for the Provider and its operations .. Appointment appointments. Reminders. We may use or disclose health information to remind you about

Treatment Alternatives and Health-Related Benefits and Services. We may use or disclose your health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

P.2 of 5
K13017 -0017

m.

USES A.ND DISCLOSURES

WITH YOUR AUTHORIZATION

Except as described in this Notice, we wiII use and disclose your health information only with your written Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your heaIthinformation for the purposes covered by that Authorization, except where we have already relied on the Authorization. IV. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION Listed below are your rights regarding your health information. Each of these rights is subject to certain requirements, limitations and exceptions, Exercise of these rights may require submitting a written request to the Provider. At your request, the Provider will supply you with the appropriate form to complete. You have the right to: You have the right to request restrictions on our use or disclosure of your health infonnation for treatment, payment, or health care operations. You also have the right to request restrictions on the healthinformation we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care. We are not required to agree to your requested restriction (except that if you are competent you may restrict disclosures to family members or friends). Ifwe do agree to accept your requested restriction, we will comply with your request except as needed to provideyou emergency treatment Access to Personal Health Information. You have the right to inspect and obtain a copy of your clinical or billing records or other written information that may be used to make decisions about your care, subject to some exceptions. Your request must be made in writing. In mort cases we may charge a reasonable fee for our costs in copying and mailing your requested infonnation.

ReQlJest Restrictions.

·J

We may deny your request to inspect or receive copies in certain circumstances. If you are denied access to health information, in some cases you have a right to request review of the denial. This review would be performed by a licensed health care professional designated by the Provider who did not participate in the decision to deny.

Request Amendment.

You have the right to request amendment of your health information maintained by the Provider for as long as the information is kept by or for the Provider. Your request must be made in writing and must state the reason. for the requested amendment.

We may deny your request for amendment if the information (a) was not created by the Provider; unless the originator of the infonnation is no longer available to act on your request; (b) is not part of the health information maintained by or for tile Provider; (c) is not part of the information to which you have aright of access; or (d) is already accurate and complete, as determined by the Provider.

.

deIrlarand the right' to submit a written
."
,~.

If

we

deuy your request for amendment, we will give you a written denial including the reasons for the statement disagreeing with the denial. . . of Disclosures. You have the right to request an "accounting" of certain

RequeSt .an Acconnting

on .our behalf, but does not Include disclosures for treatment, payment and health care operations. disclosure made pursuant to your Authorization, and certain other exceptions.

disdoSute~'ofyourhealtb

information. This is a listingof disclosures made by the Provider or by others

To request an accounting of disclosures, you must submit a request in writing, stating a time period beginning after AprilB, 2003 that is within six years from the date of your request. The first accounting provided within a 12·montb period will be free; for further requests, we may charge you our costs. Request a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. In addition, you may obtain a copy of this notice at our website, www.theconnectioninc.org.

)

P. 3 of 5

K13017 -0018

Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests. V. SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC. AND BIV-RELATED INFORMATION SUBSTANCE ABUSE

For disclosures concerning health information relating to care for psychiatric conditions, substance abuse or I-ITV -related testing and treatment, special restrictions may apply. Except as provided below and as specifically permitted or required under state or federal law, health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your special authorization. . • Psychiatric information. If needed for your diagnosis or treatment in a mental health program, psychiatric information may be disclosed. Certain limited information may be disclosed for payment purposes. HIV-related payment.

• • VI.

information,

mY-related information may be disclosed for purposes of treatment or

Substance abuse treatment If you are treated in a specialized substance abuse program, your special authorization will be needed for most disclosures, not including emergencies. FOR FURTHER INFORMATION OR TO Fn.E A COMPLAINT

If you have any questions about this Notice or would like further information concerning your privacy
rights, please send a written request to:: The Connection Inc. Privacy Compliance Official 955 South Main Street Middletown, CT 06457 If you believe that your privacy rights have been violated, you may file a complaint in writing with. the Provider or with the Office of Civil Rights in the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint To file a complaint with the Provider, you must submit your complaint in writing to: Privacy Compliance Official, The Connection, Inc., 955 South Main Street, Middletown CT 06457. If you wish to discuss your complaint, you may call the Privacy Compliance Official at 860-343-5500. VII. CHANGES TO THIS NOTICE

.')

We reserve the right to change this Notice and to rom the revised or new Notice previsions effective for all health information already received and maintained by the Provider as well as for all health information we receive in the future. We will provide a copy of the revised Notice upon request Page 5 of 5 of this ·document, signed receipt of "Notice of Privacy Practices", is on file at location.

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P. 40£ 5

K13017-0019

Alternative Incarceration Center
-,

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Client Acknowledgement form (To be kept in client file)

I hereby acknowledge that I have received the HIPPA Notice of Information Practices and I agree to read it in its entirety.

Date

Date

)

10/3112005

K13017-0020

Alternative Incarceration Center
Audio and Video Tape Consent Form
, I consent to the observation, tape-recording and/or videotaping of treatment sessions so . long as the said procedures are done under the-supervision of the professional staff. This information will be utilized for training of staff and for furthering my treatment.

All materials obtained are protected from disclosure by Federal Regulations CFR 42~ Part 2. None of the materials can be released for any purpose other than the above stated without specific signed consent of the participants. (Public Law 93-282, 1975)*

*

)

K13017-0021

State of Connecticut Judicial Branch
Consent and Release Authorization Form for PhotographyNideo Use and Distribution
I, (Insert name), -l.:(ln~se~rt~T!..!::it1~e:.b). duIyauthorized, am acting herein on behalf of _____J(I.:::Ins=e~rt name of Alternative Incarceration Center), hereinafter collectively referred to as "Contractor". Contractor gives the State of Connecticut Judicial Branch, hereinafter "Judicial," the nonexclusive, irrevocable. perpetual, royalty-free, worldwide rights to use, reproduce and publish photographslvideos of its adult clients in any and all publications created by Judicial. in any and all presentation formats. for program. publicity, exhibition. instruction, research or any other purpose. Contractor represents that all client photographs/videos were taken or created by Contractor with the written permission of its adult clients and are copyrighted by Contractor. Contractor expressly releases and discharges Judicial, its agents, officers, employees, authorized representatives and assigns from any and all liability arising out of, or in connection with, the use, distribution or reproduction of the photographs/videos.

--)

In the event that any materials contain the work of other individuals or organizations, Contractor understands that it is Contractor's responsibility to secure any necessary
permissions and/or licenses and to provide Judicial with copies of the same.

The Contractor hereby agrees to indemnify and hold Judicial, its agents, employees, public officials and representatives harmless from any and all claims, causes of action, demands for damages, or liabilities of any kind, including the reasonable costs to defend such actions regardless of whether such action is successful or not, brought by any person or entity whatsoever, arising from the failure or alleged failure of the Contractor to secure any necessary permissions and/or licenses to use the work of others. that I have read this authorization form and agree to its terms, I am authorized to sign this form, and that I have obtained the necessary rights andlor permissions to use the work of others.

I acknowledge

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Name and Title (please print)

Date

,3jzW2

K13017-0022

AUTHORIZATION FOR RELEASE OF INFORMATION
CI;~tName,i14:A ~ It

bU_o.~m~;;:-HM=;j~: .
Phone (if known): The nature and extent of Protected Health Information to be used or disclosed:

)(a"lljq§r~

ofBirth:

S/um

Subject to the statements pnnted on the back. 1, the undersigned client, hereby authorize Meriden Ale to use my Protected Hea1th Infonnation for the purposes described below, andlor to obtain Protected Health

x

Date of admission and discbarge Other information, specifically:

X

Diagnosis

_x__

Lmrunwonson~l~wre:,

Treatment notes _ __

This Authorization a~d any information of: Supervision

released under it are to be used for the spedfic purpose(s)

I understand that my Protected Health Information may include alcohol andlor drug treatment records protected by federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records. 42 C.F.R. Part 2. medical information protected under the federal privacy rules of the Health Insurance Portability and Accountability Act of 1996 ("HlPAA"). 45 C.F.R. Parts 160 & 164. and lllV..;related and psychiatric information proiei::ted under Chapters 368x and 899 of the Connecticut General Statutes. and that by signing this Authorization I am agreebig to its use Dr disclosure. I also understand that I may revoke this Authorization at any time by notifYing the privacy officer of Meriden AlC in writin& except to the extent that action bas been taken in reliance on it. ... This Authorizationt
if not revoked, wiD expire:

__x__

ninety (90) days after I have completed my evaluation and/or treatment at Meriden Ale; OR

Other. ~-- __ --~----~----------~--~~~----~~----(Specification of the date, event or condition upon whlcb this authorization expires)

whetlier- Or Dot I signih'is bthorlZation and that I may-refuse to sign it In certain limited c.ircum$tances., however, I denied treStment if I do not sign a consent form for disclosures relating to treatment, pa~~ ~r WQ~ .oper:ations. I tmdi:rstand that under applicable law 'the information disclosed under

I

un4emand ftlat generaUyMerideo

AJC maj notcondjpon

my treatment or continued treatment on

mw·be

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authorized

byth'e:.fe4¢~: recjpie~tS entItiedio a

this

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who copy

be s~bjt:ct ~ disclosure by .the reCipient and thus. may no longer be protected privacy rules "!.olderHIPAA. Such infom'lation. however, continues. to be pretested for are subject to the appliCable confi~entiality laws mentioned above. I understand that I am ,of this authorization form, I ·agreethat a copy of this authorization will be as valid as the

~er

CIi~Si_~aL
Relationship to Client

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Signature of parent, guardian or legally representative

K13017 -0023

!Attachment
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El

The Connection, Inc. Client Rishts and Responsibilities
What are my rights?
You have the right to: :. • • • • • • • • What Be treated fairly and with respect regardless of race, ethnicity, religion, mental or physical disability) sex, age, or sexual orientation. Participate in making your individual service/treatment plan, Have your protected health information kept private. Receive services in a safe place. , Agree to or refuse treatment services, unless they are court ordered. Get information in your own language or have it translated. File a complaint, appeal or grievance without penalty. Receive good care from providers who know how to take care of you. Your human, civil, constitutional and statutory rights will be protected at all times. are my responsibilities?

You have the responsibility

-'.,

to: • Give information needed for your care to your service/treatment providers. • Follow instructions and guidelines from your service/treatment providers. • Arrive on'time for all appointments, • Tell service/treatment providers if you have to cancel an appointment before the scheduled time. • Participate in creating your treatment or service plan. • Be aware of your rights. • Assist in progressing towards your recovery or rehabilitation. • Take care of yourself; and • Treat others with respect and work cooperatively with others. • Ask questions when you do not understand the care, treatment, or services you get or if you are unclear about what you are asked to do. • Meet financial commitments for services Y9U get • Accept responsibility for your actions or decisions if you do not follow prescribed service/treatment or your service/treatment plan.

I have received a copy of my client

right and responsibilities and they have been reviewed with me by

staff.

Date:

~ -£7-c:rr ----~~~--~--

, )Staff

Signa

K13017-0024

()
1{_1f}1!/5d.~VS/c Ii have read and understand the . ~rIDation on SexuaHYT mittedIDisease (SID). Also, an AlC staff member has reviewed this packet with me. If I have any questions, I will ask an Arc staff member to explain the information I don't understand or consult the community resource directory in my client handbook.
I received the client handbook as part of my intake/orientation.

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Date: 6129/07 Client Name: Komiswjevsky, Josh
Date of Admission: 3127/07 To.: 95 Scovill Street, Waterbury, Ct Assessments Completed: LSI-R _19 __ (Pre-triaVParole only) ASUS _18 __ (Pre-triallParole only) SAl __ (Pre-trial/Parole only) Group Track: Cognitive Skills __

}

Meriden AIC 174 State Street Meriden Ct 06450

June 2007Montbly Report

DOB: 8110/80 Date of Discharge:

Group Track: Cognitive Skills _X_ Employment Services Substance Abuse Group

X_

# of days scheduled

to attend __
_

Employment

Reason for absence (s) _--::-# of days scheduled to attend __ # of days attended Reason for absence (5) Substance Abuse Group __ # of days schedu7Ied--=-t-o-att-e-n--:d:-_-_-_-_-----------Services __ # of days attended Reason for absence (5)
_

# of days attended

)

Levelof Participation:
Excellent Individual Contact: Good __ X__ Fair Needs Improvement # unexcused absences _

# of sessions

------

----_
_ _

Urinalysis: Dates and Results :6n=neg, 6128==neg Community Service: # ofbours assigned Employment Status: ScboolStatu~ Special Conditions: Currently employed _

#

of hours completed

Actively seeking employment

as,the 'h~d rO.j'em8~.dl.e·prO'ti4~· y:stu.,s 0" a w~kJy:"as~Jor·:pr9'of o{ e~p,o'y.p'i~!i~lIe'att~~~'w.~J4Y· ..
group every Tuesday evening' at the JDstitute of Living,
Cue Manager_VanessaF~"':B,.n'.

Co~ments:

~r. ~o~~,ar~~!~~.~

e.IIl.,Jo1.«:.d. a fuD on

tinl~ ~asis..wi •.~ t~e

HaI_jf0rdRest0l1'ti()n

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t~isCop..q~Jor ~~c~)lirage:!i Ko'~ islirjeVs~. tb see~ counsel· ~egai.di~g'~Qes Br'O"h!I !'dr. bis custody.medlation fot itis ,d~l!.gbter~'Mr.KCllri~rjtlv~J'.Y contili.ues.o ·ch~h·:.aCo~aine t Anonymous s",pport
recovery. In ad~itiim

i~.dMdualseSs!o~siffib·"~iS·~ter:ev~iY TInirS(lar.

TheJ~us·<!rtb·ese:diScussi~os.is'~is ~.~!!:~if~lds

'm support

of-his rec;overy.

".

Program Director

~tvj./»um:l

CAC.CADC_

Date_6(29/07
Dale

----=-9¥<=:~~JfH.~--

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K13017-0027 If"

Meriden Ale 174 State Street MeridenCt 06450 May 1007Montbly Report

Date: 5131101 CtientName: Komisarievsky, Josh Date of Admission: 3/27/01 To: 95 Scovill Street, Waterbury, Ct
Assessments Completed:

DOB: 8/10/80

Date of Discharge:
Group Track:

LSI-R _19 __

(Pre-triallParole only)

ASUS_18_._{Pre-triallParole only) SAl __ . _ (Pre-triallParole only) Group Track:

Cognitive Skills_X_ Employment Services Substance Abuse Group

X_

Cognitive Skills __ Employment Services __

# of days scheduled to attend # of days attended -Reason for absence (s) _--:;

_
_

# of days scheduled to attend _.__ . # of days attended Reason for absence (s) --::--_----::--Substance Abuse Group __ # of days scheduled to attend __ # of days attended Reason for absence (s)
Level of Participation: Excellent Good __ X__ Fair Needs Improvement

_

_
_

Individual Contact:
Community Service: Employment Status:

# of sessions

# unexcused absences # of hours completed Actively seeking employment

Urinalysis: Dates and Results :5/HFoeg, S121=neg # of hours assigned
Currently employed

_ _

SchooIS~hm:

-----------------------

Sp~~MC~~ditioits: _C~~~~~f:!~-:-~r.. (~~!~rj~V$~,~~ J ,_~IIiPloi~(~!1.:~~JI-~Il!,e. ~sis wi~b t~.e-i:J~rtio~~:¥:~t~n-tion S~rvic~, I~~ a ~ as·@!e\fiiaClioi'eniaii ..:He:;--roViil ':' a :Stdtis.66 '8 ,W'eekJ.:basisfor i<Jof ohm --10 me'ilt. ': Heattends 'WeekJ -

~i[try~-~~~~i~~:~~~r#.~ ·¥.i~~j~ry'!~~~~a.y:·~'~~~~:6rlti~~ dii~~~~;i~'~bi ~~j.f_~fu
J

biS$...i(O~i:·~¢ij_I~J~9i(f~i:J9$ .. a:~g~w.r.~-Mr: a ~*fd~_rjevskY ~ttendS coinpl,~~ t~e Tre8ti~gAlcobol - DepeD4ence-grod~:oil.5al/07· . -, ,-,'
Case Manager _Vanessa Fitzner-Brone, CAC,CADC_ Program Director
j,

rt(:'~W"ty~'r,n. ~~4~,~()n~:~~';~nii!_-~¢lOreDco~ ~ge§J'tff.1.'o~~TJeyskyto

~~~ b~ _see~icounsel regar()u,g psues around

fklbuotf

Date

5/31107

_

Date

-----¥"-,~f-'l-'F-1sjo"""--L..1--

K13017-0028

Meriden AlC
174 State Street

Meriden Ct 06450 April2007Monthly Date: 4/30/07 Client Name: Komisarjevsky, Josh Date of Admission: 3127/07
To: 95 Scovill Street, Waterbwy, Ct Assessments Completed: Report

DOB: 8/10/80 Date of Disc barge:
Group Track: Cognitive Skills _X_ Employment Services

LSI-R _19_ (Pre-triaJ/Parole only) ASUS _18__ (Pre-triaIIParole only) SAl __ (Pre-tJiaVParole only) Group Track: Cognitive Skills __

Substance Abuse Group

X_

# of days scheduled to attend # of days attended -Reason for absence (s) Employment Services # of days scheduled to -att:-e-n-=d:------------------# of days attended -Reason for absence (s) -:--::-- __ ::-Substance Abuse Group __ # of days scheduled to attend __ # of days attended Reason for absence (s) ) Level of Participation:
Excellent Good __ X__ Fair Needs Improvement # unexcused absences _

_

_

Individual Contact:
Urinalysis:

# of sessions

------

-------__
_

Dates and Results :4!3=neg, 4/23=oeg # of hours assigned # ofbours completed

Community Service:

Employment Status: SmoolSta~:

Currently employed

_

Actively seeking employment

~,~,.~.--

__ ~------------~~--~---------------------

Specbtl·COllditlODs:·. . .ComaD~ts:. ~ -,KO~liiJ~v.~ky~is·,~l;D,p.oy¢. pDaJ~U~.~e~aSis''Yitb the ·Hartford R~oratioi1·Servicest.nc as the ·1I~d fo~J!la~::.,~I:iepto!ides·.p!lysht~s·ooa wee~ b~5is for proof of employment. .He. atteli'ds ~eekly ·iDdivia~~1 ~5}hJ;l~'~,~ls::Wiit~i' ev¢iyThiirsfJay."lIietQfiji·ofthese discussioJ]sis hiS ~eif:esteem aD~ ·his recovefi.:·· iii afJ~i#~~·~U.iill: c;9~~~r()re~c6un.ge.,$i~ri~9mis~rj~vsky ·to s~k counseling. for his. post suicidal idea~on: priOI' fO g~~~.,~ p~Oil.'··Mf.Komi~rj~!sky~~D~ the Treating JUcohol DependeoCe.groups on MOD & Wed eveniD~ He.·has not missed a group to date. Case Manager _Vanessa Fitzner-Brone, CAC,CADC_ Program Director
...

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Date _4/30/07 Date

0k
K13017-0029

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129/07

GRAHAM-MASSEY ANALYTICAL LABS INC. 60 TODD ROAD SHELTON CT 06484 PHONE: (203) 926-1100 FAX: (203) 944-9189
I

PAGE

1

CESSION # ECIHEN 1D GUISITI0N #
MARKS

725922 AIR # : KOMISARJEVSKY. JOSH 01947322 DOB :

FINAL REPORT COLLECTED 06/28/07 RECEIVED 06/29/07 06/29/07 FINAL RPT

8T

RESULT Urine 278 NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE

REFERENCE RANGE SCREENING CUTOFF"
)- 20
100

UNITS mg/dL ng/mL ng/mL ng/mL ng/mL ng/mL

eatinine. CAINE
IATES
?

YCODONE

,..
w

150 300 25 50

o

~# 2009 !IDEN A IC tIDEN,

CAP
CONN. REG.

#:
#:

4145601
CL-0484

~ STATE STREET
CT 06450

- ATTN:

GORDON

MACGILLIVRAYCLIA

DIRECTOR

REG.

~: 07D0686807

T. J.

Ti ng h i te lla, Ph
K13017 -0032

r7 ... __

108/07

GRAHAM-MASSEY ANALYTICAL LABS INC. 60 TODD ROAD SHELTON, CT 06484 PHONE: (203) 926-1100 FAX: (203) 944-9189

PAGE 1

CESSION #: ECIMEN ID GUISITION it "'lARKS

JOSHUA, KOMISARJEVSKY
01909174

711460

AIR # : DOB :

FINAL REPORT COLLECTED 061 071 O"}-RECEIVED 06/08/07 FINAL RPT 06/08/07

3T
:!atinine, Urine :)HETAMINES :AINE lATES
:)

RESULT
28

REf"ERENCE RANGE SCREENING CUTOFF

UNITS
mg/dL ng/mL ng/mL ng/mL ng/mL

"

~

NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE

>
25

20

1000 150

ng/mL

300 50

)# IDEN

STATE STREET - ATTN: IDEN, CT 06450

2009 AlC

GORDON

CONN. REG. MACGILLIVRAYCLIA REG. DIRECTOR

CAP

#: 4145601 #: CL-0484 #: 07D0686807 T. J. Tinghitella,

Ph

K13017-0033

122/07

o

GRAHAM-MASSEY

PHONE: (203) 926-1100

SHELTON, CT

60 TODD ROAD

ANALYTICAL LABS INC.
06484 FAX: (203) 944-9189

PAGE 1

CESSION #
"lARKS

ECIMEN ID 3UISITION #

699447

KOMISARJEVSKY, 01909207

AIR # :

JOSHUA DOB :

FINAL REPORT 05/21/07 COLLECTED 05/22/07 RECEIVED 05/22/07 FINAL RPT

3T
:!atinine, UT' i ne
'HETAMINES

REFERENCE

RESULT
170

SCREENING :> 20
1000 150 300 25 50

RANGE CUTOFF

UNITS mg/dL ng/mL ng/mL ng/mL ng/mL ng/mL

:AINE [ATES
l

NEGATIVE

NEGATIVE NEGATIVE NEGATIVE

NEGATIVE

!)
\.

J#

IDEN

IDEN,

CAP #: CONN. REG. #: STATE STREET - ATTN: GORDON MACGILLIVRAYCLIA REG, #:

2009

AIC
CT

4145601

06450

DIRECTOR

CL-0484 07D0686807
T. J.

Ti ng h i te 1.1 a,

Ph

K13017-0034

,.

PAGE 1

;/11/07
,

c~t 1,,0 L# #

GRAHAM-MASSEY ANALYTICAL LABS INC. SHELTON. (203) 926-1100

I~

60 TODD ROAD
CT

,!

06484

PHONE:

FAX: (203) 944-9189 FINAL REPORT
05/10/07 05/11/07

:CESSION :GUISITION
~MARKS

'ECIMEN ID

KOMISARJEVSKY, 01909238

692569

AIR # :

DOB :

JOSHUA

COLLECTEO RECEIVED

FINAL RPT

: 0:5/11/07

:9T eatini ne. Urine IATES

RESULT
148

REFERENCE SCREENING
). 20 1000
150

RANGE CUTOFF

UNITS
mg/dL

IPHETAM INES

!CAINE p
C

NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE

300 25 50

ng/mL ng/mL ng/mL ng/mL ng/mL

..~)
.'.

~) #: 2009 BDEN AIC HDEN.

CAP

~ STATE STREET - ATTN:
CT 06450

GORDON MACGILLIVRAYCLIA

CONN.

DIRECTOR

REG.

#: REG-. #:
#:

4145601 CL-0484

07D0686807 T. J. Tingh itella,

Ph

K13017-0035

U24/07

()
:CESSION # 'ECIMEN 10 :GUISITION # ~MARKS

GRAHAM-MASSEY ANALYTICAL LABS INC. 60 TODD ROAD PHONE: (203) 926-1100
SHELTON, CT
06484

PAGE 1

FAX: ~203} 944-9189 FINAL REPORT COLLECTED 04/23/07 RECEIVED 04/24/07 FINAL RPT 04/24/07

KOMISERJERSKY,
01857257

679792

AIR # :

JOSHUA DOB :

:8T

RESULT
81

REFERENCE SCREENING
20 1000 150 300

RANGE

CUTOFF

UNITS
mg/dL ng/mL

e a t i n i n e , UrinE ;F!HETAM r NES

;CAINE
p

lATES

C

NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE

>

25 50

ng/mL ng/mL ng/mL ng/mL

~rDEN EDEN,

J

-# 2009
AlC

CAP

#:

4145601

CONN.

REG.

4 STATE STREET - ATTN:

CT 06450

GORDON MACGILLIVRAYCLIA REG. DIRECTOR

'l*: #:

CL-0484

0700686807 T. J. Tinghitella,

Ph

K13017-0036

4/04/07

()
:CESSION # ::IECIMEN 10
=:aUISITION
~MARj.\S

PHONE:

GRAHAM-MASSEY ANALYTICAL LABS INC. 60 TODD ROAD SHELTON, CT 06484
(203) 926-1100 FAX: (203)

PAGE 1

944-9189

#

01857302

666149 AIR # : KOMISAR~EVSKY, JOSHUA
DOB :

FINAL REPORT COLLECTED 04/03/07 RECEIVED 04/04/07
FINAL RPT

04/04/07

:5T 'eat:inine,
]CAINE

RESULT
Urine 72

REFERENCE RANGE SCREENING CUTOFF
:> 20
1000 150 300 25 50

UNITS
mg/dL

1PHETAMINES
'IATES
;p

~c

NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE

ng/mL
ng/mL

ng/mL ng/mL ng/mL

c)

~09

CONN. REG. #: RIDEN AlC #: REG. 4 STATE STREET - ATTN: GORDON MACGILLIVRAYCLIA DIRECTOR RIDEN, CT 06450

CAP

#:

4145601

07D0686807 T. J. Tinghitella,

CL-0484

Ph

K13017 -0037

Random Drug Testing
I understand that I am required to remain drug free while participating in the Alternative Incarceration Center services. I understand that every time I report to the Ale, I should be prepared to provide a urine sample upon my arrival ifrandom drug tests are ordered by the referral source, I understand I must render a supervised urine sample whenever requested by an AlC staff member. Once a urine sample bas been requested, I must remain at the Ale facility until I have provided the sample. I will be permitted to drink a reasonable amount of liquid. I, understand that failure to render a specimen by the close of business or within 2 hours of . a request, will be considered a urine stall and positive for drug use, for the purpose of determining consequences. Failure to render a urine specimen will be conveyed to the Court and/or my ProbationlParole Officer and may jeopardize my opportunity for success.

/client

~~;,~..,J_
Signature
Signature

Due to the substantiated

reliability of the test results, fe-tests will not be permitted.

.

"5r-#-T-cJ7
Date

ri:

(if'required)

() Witnf,f+~
ALCOHOL TESTING

.l3/Jr/oZ
Date

Date

I understand that I may be required to submit to random alcohol tests, if ordered by the referral source. If a positive result is obtained, I am aware that it will constitute a breach of my Ale conditions and regulations, as well as being reported to the Court and/or my Probation/Parole Officer. I am also aware that if it is determined that any alcohol is in my system, I will be instructed to leave the Ale premises immediately. and will be required to return the following day to discuss any consequencesof my behavior. .

Date

Date

$21&1revised 10/05 K13017-0038

THE CONNECTION, INC. MERIDEN AlC
174 State Street Meriden, CT 06450

(203) 639-3969 Fax: C203} 639-3967 www.TheConnectionlnc.org' A Connecticut Human Service & Community Development Agency

To:

From:
Pages: Date;
.Cc:

Fax:

G

MESSAGE:

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nON-n-· DENTIAUTY

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1

NOTICE ThIs communication, incJudilJgal1:achments, Is for the: ex~Jusjve use of addressee and may contain proprie.tar)1, confidential or prNiYegecIinformation. Also, the confidentJaJilY the information contained in this a-mail, indudlng any attachments, may be protected by Federal end Connecticut State taws. if you are not the intended recip{ent, ,my USe, copyin{" disclosure, dtesemtneticm or distrfbutirm is strictly prohibited, If vau ate not the Intende.d reCiplf:lflt please notify the sender Immediately by return e-mail and delete this communication and all cootes.

or

==------'

K13017 -0041

THE CONNECTION,

INC.

MERIDEN Ale
174 State Street Meriden, CT 06450

(203) 639-3969 Fax: (203) 639-3967
www.TheConnectia.nlnc.,org A Connecticut Human Service &. Community Development Agency

C()NFrm~NT1ALrrY NOTICE This ,ommunfcatJofl, including attachments, is for tne exclusive use of addressee and may 'Contain proprietary_ confidential or prIVileged lnfarma, on. Also, the confidentia/{ty of tbe information contained in this e-mail, induding allY al:taclrments, mily be protected by Federatand COnnecticut State Laws. If you are not the intended recipient, ,my use, COpyIng, disclosure, dissemination or distrlbuUon is strictly prohibited. If you are not the iflte.ndecfrecIpIent, ptesse notify tile sender immediately by return e-mett and delete t/as communtce ion and all copies.

------------------

-

-----------------------~

K13017-0042

o

F;IfORMS\dicudledu~WPD

MERIDEN AIC • CLIENT WEEKLY SCHEDULE WEEK OF

,-'/JlJ - 7/26,1D7
JD'Eh LtaATU
NC.D/PO:
SCHEDULE

CLIENT NAME:

~)S~YS\C'I,
\{ B'r)efE:Q

S:

CAS E MANAGER:

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FRIDAY

MONDAY

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CONDITIONS'
PHYSICAllY REPORT CALL XsfwK Xsfwk SCHOOL REPORT hrslwK I/. groups perwk COMMUNITY SERVICE FAMILIES IN CRISIS Yes hrslwK Attend Xs/wk

IN
WORK N.AJA.A.

J

JOB SEARCH SUBSTANCE ABUSE ED.

XsfwK

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K13017-0043

MERIDEN Arc - CLIENT WEEKLY SCHEDULE

..--..,
'.,
:

CLIENT NAME:

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FRIDAY

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TIME IN

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'CONDITIONS
CALL Xs/wK Xsfwk SCHOOL REPORT hrslwK COMMUNITY SERVICE FAMILIES IN CRISIS Yes No hrsfwK Attend

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IN
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XslwK #
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# groups

K13017-0044

MERIDEN AIC • CLIENT WEEKLY SCHEDULE WEEKOF CLIENT NAME:

'112 -i/4Ci7
,/, JDEJW&-TUS:
,NC.D/PO:
SCHEDULE

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K13017-0045

rrequismon rsumoer.
01,947322
50 TODD ROAD • SHELTON, CT 06~4·5342

AcceSSIOn Number:

Phone (203) 926-1100, (800)288·6365, Fax (203) 944·9189 Conn Reg. It CL-0484, ellA #0700686807 CAP #4145601
L.,;-:':"_';'_---l!~QlI.WIL.Ja.!C!oImw:!J.!!i.Wl_';;_~:":';"'

-I DATE

OF COLlECTION

TIME

'RI DEN A I c TN; GORDON f'1ACG!L 4 STATE STREET

Acct. # 2009
rVRA'

A P.

RIDEN. CT

06450

o Olher

_

Jr which a physician's BUlhorizallon is on file at·rts labOratory.

II posltive screening results wm be confirmed by a second test unlessotllolWiSil requested. Orouting physfcianl;l. shourd .be aware that govemmenl p:rograms only p~ lr testing that is medically necessary. Changes to this requesflorm may be made at the request of Ine authorizing physician. Graham-Massey will only perform !estir

'ESTS

Please Mark

Appropriate

iBoxes Befow For Tests or Panels DesIred

o

o

Amphetamines (Includes MDMA)

0

Cotinirre {nicotine metabolite)

0 Dextromethorphan D Benzodlazepines 0 EDDP (methadone metabolite) o Buprenorphlns (Suboxone, Subutex) 0 Ethanol (alcohol)

Barbiturates

o o

o o o

o

o o

Methadone Methaqualone Opiates (codeine, morphine, heroin metabofij Oxycodone (Percodan, Percocet, Oxycontir Phencyclidine (PCP) Propoxyphene (Darvon, Darvoeet) Riboflavin (protect from light) PANEL:

Oannablnoida (THO) Quantitative Cannabinolds (THO) Qualitative

0

Hydro.coctone (Vicodin, Lortao)

o

"1 Cocaine metabolite
SPECIAL REQUESTS AdulteratIon Panel (limited to pH. specific gravity. nitrites, chrornates)

D Hydrornorphone (DUaudfd) 0 LSD (protect from light)

o

Meperidine (Damera!)

o

OTHER: o

_
OIlS
Ar1 H

CONTRACTED

o
o

Urine Pregnancy Urinalysis

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. GRAHAM ..MASSEY
It

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Security Seal

t. Attach label as shown. 2~ VerilY thaI t code numm match with' request rom 3. Retain yeUo

copy .

Apply bar code label vertically on bortfe.

rev. 10,
CLIENT COpy

K13017-0046

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K13017-0048

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K13017-0051

i1~ljUI~H1011I~um[)er: AN A l V T lOA L
l. It B Sf

AcceSS10n

rsumoer:

N '0.

01909174

60 TODD ROAD .. SHELTON, CT 06484.5342

Phone (203) 926-t100, {SOO} 8$-6365; Fax (203) 944.9189 2
Conn Reg. 11CL·0484, CUA #0700686807

CAP #4145601

Acct. ilOE-lAiC fN: GORDON t'1ACG LLIVRAY 4- STATE STREET
~IDEN,C 06450

# 2009

DATE OF

co. L. E;~ ~
Urine

J--------.:l..<2. l_~ Specimen T~: '

{;~7L·· __

_L__....=::======
_

p.

OOther~

I posaive SC1'eetlng results wiU be confirmed bof a second test unless otherwise reqtl~ste(L Oloortng physicians should be aware tha~govemmant ~whicl1 a phYSician's authorization is on fife at its laboratory.

prograrnsonly

pa

tasllng that is medfcafJynecessary. ChangeS to this request form may be made at the request 01100 authorizing pl'lysiclan. Graham-Massey wit! only peJform tastln

ESTSPlease

Mark Appropriate

Boxes Below For Tests

or Pa'1els-=De~· :..::s~lr=.~-=·

_ Methadone Methaqualone Opiates (codeine, morphine, heroin metaboUt Oxycodons (Percodan, Percocet, Oxycontin PhencycHdine(PCP} Propoxyphene [Darvon, Darvocet) Riboflavin (protect from light)

o o
o o

o
o

Arnpttatamlnes(includes MDMA) 8arbrturates Benzodiazeplnes Buprenorphlne (Subol(one. Subutex)
Cannabmolds (THO) Quantjtatlve

0 Gotlnine (nIcotine metabolite)
0 Dextromethorphan

0 EODP (methadone metabolite 0 Ethanol (alcohbl)
0 0 0 Hydr'ooodone (Vicodln, Lortab) Hydrornorphone (Di1audid) LSD (protect from fight)

.

o o o

o o

n

Cannablnolds (THC) Qualitatlve

'l Cocaine metabolite

,,~

o

SPECIAL REQUESTS o Adulteration Panel (Hmited to pH, specific gravity, nitrites, chromates) o Urine Pregnancy o Urinalysis

o Meperidine OTHER: o

(Dernerol)

__
6118 MPH.

CONTRACTED

PANEL:

ON

lS
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OPT~!"1
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t]TH·'

CREAl'

L Altadn .labal as Shown.
2. Verify that

.. GRAHAM-MASSEY
AN .A L Y TIC ALL All,S I

2 c.

Security Seal

3. fuitaln yaffo
copy. Apply bar coda label
vertically on bottle.

code numb. match with· request lorn

rev. 10 CUENTCOPY

K13017-0052

F:IfQRMSIdj~l

e,Wl'O

MERIDEN AIC • CLIENT WEEKLY SCHEDULE WEEK OF

CLIENT NAME:

born

CASE MANAGER:

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I

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JOB SEARCH SUBSTANCE ABUSE ED.

Xs/wK

#
groups per wk

ND

K13017-0053

MERIDEN AIC - CLIENT WEEKLY SCHEDULE WEEK OF

CLIENT NAME:

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SCHEDULE
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Xslwk hrstwK # groups perwk
SCHOOL REPORT COMMUNITY SERVICE: FAMILIES IN CRISIS Yes

I
Xslwk hrs/wK
Attend

IN
WORK

JOB SEARCH SUBSTANCE ABUSE ED.

XslwK 11 groups per wk

N.AJAA

No

K13017-0054

HARTFORD RESTOF.\ATlON ·SERV1CES.INC. Employee Joshua A Komlsaljevsky. 199 Retreat Avenlle, HartfOro. CT 06106 Hourly Consllud!on Taxes 26.50 21.00 .
Rate Current SSN . Status (FedlSlate)

,"UvOU '''--4756 SlngIeJW!Ihholding Code A Pay Period: 05l1at2007 - 05119/2007 YTOAmoIInl 12.,838.50 YTOAmollOt -1.379.00 -783.48 -183.23 . -417.39 .2,783.08 9.873,42 AllowancesiExUa
Fed-1I01ct.fJ/O· .

Pay Date: 0512.212007

556.50

FecJe181 w~ng

Soda! Security Employee Medicate Employee
CT - WIthholding

Current '-59.00 -34.50 -8.07 -15.52 -117.09 439.41

Net Pay

.._ .'

K13017-0055

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