‘Do you smoke or use tobacco products? EVes | No Have youevertriedto quit tobacco? MEYes | No ‘What substances are you using now: (SC ‘Do you experience withdrawal symptoms when you stop using substances? [Yes BENo tyes, what re the symptoms? (Seizures, D's) oe _ ‘Are you pregnant o do you suspect youare pregnant? [Yes EENo if Yes,howmany wocks?:_1\)) Px If Yes. Have you seen a physician/practitioner for your pregnancy? PYes No Who? Whe Have you had an ultrasound date’ \Who is physiciah/pracitioner who prescribes your medications: Phone ‘What pharmacy (s) do you get your medications from? $e. G0 3903 Phone Current Medications and Dosages: * You mi fcatfons list from Gcceoun ae =e oma 7 good Tair as poor Why — — ‘What is your height? 574" Weight? [XK . Current Medical Issues (aboies, ear disease, iver disease, 6): ‘Any special medical needs/accommodations (wheelchair, hearing, vision —— ‘Current Diagnosis: Substance Use Disorder. — New Heath PTSD | Sere LKR Number or prior treatments: Inpatient 3 Outpatient _ Longest period of abstinence following any treatment episode: _(QOQONtN + Have you received treatment at MCDC inthe past?! ~"YesOLNo- When Did you complete: [Yes [No Have you ever used drugs by injection: [Newer ~ Currently Using [Last -12 Months SE More than a year ago MB Ves No Other: Do you presently havea sponsor? [es WENo _ Have you been involved with AA or NA grou Hive you been incarcerated in the last 30 days? flYes [No How many days? = lease list all legal involvement (Current and Prior): Bad Cmecks (one eee imineal Sardernag cones ‘ ‘Are you required to register sa senualiofnt offender? [Yes RE No Are you: as Probat “Mandatory Monitoring Hinkle) On Pre-Release DUI Offender reneeroe rn Esl Lak § mont HEC [Name of your attomey’ ming __ verve Hida the Sinetron ne SaadehGeneral power of attorney dante Atewes Bttelenc WM nerety sppsint tasen Alewerk or E.Helenz, VM asmy attoineyintatto act in my capacity to do every act that | may legally do through an attorney in fact. This power shall be in full force and effect on the date below written and shall remain in full force and effect until_ =~ \- IORO or unless specifically extended or rescinded earlier by either party. oatea_]- all 2020 Signature: print name: Melanie Alc uoer STATE OF MONTANA COUNTY OF LEWIS AND CLARK BEFORE ME, the undersigned authority, on this_2@ | __ day of Annoy 2020, described in and who signed the Foregoing, and acknowledged to me that he executed the same freely and voluntarily for the uses and purposes therein expressed. WITNESS my hand and official seal the date aforesaid, NOTARY PUBLIC My Commission Expires: AVR: | (3, 202.2 FMR IR, NOW USL me Sao Metana sane et esse ane ‘ar‘What are your recommendations/plan for the treatment and recovery of this application once they have completed an intensive in patient treatment: (Please list all: AA NA, IOP, OP, R-Tech homes, drug cour, service volunteer activities et.) rov 4reukmentk Coork ‘What plans have you bopun to address the above long term recovery plan with your patient? Signed up for 1OP : Stared compltng the Level 3.1 application process Created a plan with the PO__ ‘Started applications for health insurance_~ Sted applications for GED A Stared applications for sober ving home Stated applieation for employment X Stated applications for housing Othe _ Other — ‘ ‘Are you wlingopatipate in t east one care conference with this patient while they aren eaten; [Yes [Ne [7 NA REFERRING AGENCY : Adres iy se: tied ams of Coser eee en Signature of Counselor: Date NOTE: You may also submit a copy of your own completed Biopsychosocial that includes the ASAM assessment. RELEASES OF INFORMATION MUST BE INCLUDED WITH APPLICATION Medical Issues: If the patient has any medical issues we need Medical Records to complete this application, * Include releases for all medical providers & pharmacy the patient uses Mental Health History: If this patient has a history of Mental Health Counseling we will need Records from the provider. * Include releases for all mental health providers Legal Involvement: Include Releases of Information for Probation officers, attorneys, judges, etc. * We will not accept an applicant to MCDC without a release for the assigned probation officer. * RVO/RSO are reviewed on an individual basis.MONTANA CHEMICAL DEPENDENCY CENTER 1525 East Mercury Sirest— Butte, Montana 9701 “Telephone: 406-496-5400 Fax: 406-496-5431 aoa soe BIAS -OI44 AUTHORIZATION FOR RELEASE OF INFORMATION Extent or nature of disclosure is imited to: (Check al that apply) HIPAA standards require that you request the ‘minimum information necessary to complete required purpose ofthis release. Continued Care Plan/Transition/Discharge Summary listory & Physical “GL BioPsychosocial Evaluation/Assessment “Bait ath sacocarnt ‘BHroament ean -kprogess Nace TH Physician Orders “TrBates in program | "Medication Records Siceneral Progress in Treatment TITS Skin Test Results ‘CLietercscipinary Notes 5 Continued Stay Reviews ‘FCorespondence —“EXRecovery House Application Dato Release Revered: DOther(Ptease be specific) Purpose of need for disclosure is Permission is hereby given to EXCHANGE information with: Montana Chemical Dependency Center ‘525 East Mercury Street Butte, MT 53701 phone: 406-496-5400 fax: 406-496-5431 AND Name: Grice \vlenting /Pabtic NeSonders OKice Gry Slate WE Zp Cove: S965 See ee = OO Fax number: ‘The information you designate for disclosure wil be Gisdlosed from records protected by HIPAA privacy standards ‘and Federal Confidentiaity regulations (42 CFR Part 2). The Federal rules prohibit the recipient ofthe information from making any further disclosure ofthis information, unless further disclosure is expressly permitted by your writen authorization, of as otherwise permitted by state and federal regulations. A general authorization for the disclosure of ‘medical or other information is NOT sufficient for this purpose. |, the undersigned, have read the above and authorize staff of the disclosing facilty named to disclose such Information as herein contained. | understand that | may revoke or cancel this authorization at any time. Withdrawal ‘ofthe authorization does not affect any information disclosed before providing a written notice of such a withdrawal of ‘authorizaton. This authorization will remain in effect for 180 days in order to carry out the purpose for which ‘my permission was given. | underetand thatthe program releasing these records i fee from al legal ables that ‘may arse from this act. | understand that | have the right to limit the information that isto be disclosed and who can see “f photocopy of bis auhorzation as eid as te orginal Hin Yai putr(390/ i Signature “Faalty Wines Sqratire Dato TI 1 Cancet My Permission To Disclose The Information Described On This Form. Batint Signature ‘Dale Facility Winess Signature Date ‘Approved: Apa 2008 ‘This note accompanies a disclosure of infomation conceming a paint inalcoholdrug abuse treatment made o you with the consent of such patent. This information has been disclosed to you fn records protected by Federal Confidentiality nes 42 CFR Part) and the Health inaurance and Porabity and Accountabay Act of 1996 (HIPAA 45 C.P-R. Parts 160 & 164) Federal laws ‘hit you from making any further actos of his nfrmation unos fi expressly perntied bythe wien consent of he Berson © whom I petans oF as otterwise permed by 42 CFR Part 2 of HIPAA. A ganeal authorization forthe release of media! ‘coher Infomation i NOT sufiient forts purpose. ‘The Federal ules and laws reebic any use of te norton to ciinaly Investigate of prosecute any alcohol or drug abuse patent ‘MCDC will nt make signing this authorization x condition of treatment, payment or enrolmenteligibility for benefits ‘unless the authorization fs mandatory. Print Form Save Form Reset FormMONTANA CHEMICAL DEPENDENCY CENTER '525 East Mercury Street ~ Buti, Montana. 59701 “Telephone: 406-496-5400 Fax: 408-496-5431, Patient Name: \\i Ne §- Spi i on, (ast) (Prt) oy OPUS ss#_BV7-15-O744 AUTHORIZATION FOR RELEASE OF INFORMATION Extent or nature of cisciosure Is imited to: (Check althat apply) HIPAA standards requie that you request the ‘minimum information necessary to complete required purpose ofthis release, “Tscomfinued Care PlanTranstionDischarge Summary “SLHistory& Physical “E.ajoPsychosocal EvaluaionAssessment Dos: “ELMental Health Assessment -EL{reatment Pian ELProgress Notes ‘SLPhysician Orders $3 Dates in program Medication Records “SLGeneral Progress in Treatment “8B Skin Test Results EF interdisciplinary Notes ‘Continued Stay Reviews ‘DiComrespondence “EI Recovery House Application [Date Release Revoked: ‘Dither Please be specic) Purpose of need for disclosure is. Permission is hereby given to EXCHANGE information with: ‘Montana Chemical Dependency Center 525 East Mercury Street Butte, MT 59701 phone: 406-496-5400 fax: 406-496-5431 AND Name: Ppverr Ledoakinn zack Parole acess Cty: kel@ise, “State: CK Zip Code: S20 |_ Phone umber: Fax number The information you designate for cedure wil be delosed Wor Tacos protaed By HIPAA privacy standards and Federal Confidential regulations (2 GFR Pen 2). The Federal ues pont the recent of th information fram making any futher dscosue of ths infomation, uries further cclonue le expresly perio By your writen ‘uorzaton, oF as oherse pared by sate and federal eguatone. A genealauboreaton forte doaure of tmedca or oer infommton NOT sult forts purpose. |, the undersigned, have read the above and authorize staff of the disclosing facility named to disclose such itformation as herein contained. | understand that | may revoke or cancel this authorization at any time. Withdrawal ofthe authorization does not affect any information disclosed before providing a written notice of such a withdrawal of ‘authorization. This authorization will romain in effect for 180 days in order to carry out the purpose for which ‘my permission was given. | understand that the program releasing these records is free from all legal liabilities that may atlee from this act. | understand that! have te right to mit the information thats fo be disclosed and who can 1300 hs information. photocopy ofthis authorization is as valid as the original A I a Math Siv ct w123d Signature ‘Date “Faciy Witness Signature Date 1 Cancel My Permission To Disclose The Information Described On This Form. Patient Signature Date Faciity Winess Signature Date ‘Approved: Apa 2008 “Tis noice accompanies a disclosure of infomation conceming @ paint in alcoholdrug abuse reament made to ou wth the consent of such patent. This formation has been disclosed fo you fom record protected by Federal Gonkdenalty ules 42 CFR Par) and te Heath Insurance and Portal and Accouniabity Ac of 1906 (HIPAA 45 C.F R. Parts 160 & 164) Federal laws ‘rchiba you fom making any further disclosure of is information uness His express permed bythe wien consent ofthe person to whom pertains or as otherwise pormited by 42 CFR Part 2 of HIPAA. A gonorl authorization forthe rleaso of medical ‘Stother information NOT sufelent for this purpose. The Federal rules and laws restict any use ofthe information fo cially Investigate of prosecute ay alcatol or dug abuse patient MCDC will ot make signing this authorization 2 condition of treatment, payment or enrollment/eligibility for benefits unless the authorization mandatory. Print Form ‘Save Form Reset FormMONTANA CHEMICAL DEPENDENCY CENTER, 525 EAST MERCURY STREET BUTTE, MONTANA 59701 DECLARATION PAGE. | declare the information that ! have provided is accurate to the best of my knowledge. | hereby authorize the release to the Department of Health and Human Services to obtain‘release financial information. NameWa gon G5 ONL &e se) Ceemee ten t/ Ofte erSit og Please check below: Oe eee nee ae terre Ok fone ttn Lorn 242/202. Signature of Fianily responsible peson Date applicable please include number of dependents/children with ages. Self Dos. Social Security number Dependent Spouse DOB Social Security number_ 1 PLEASE CHECK HERE IF YOU HAVE NO INCOME BA mrease cnc were ir yoy Have INCOME 6 SOURCES USD MONTHLY AMOUNT(@_ GOO = 1 tamas.eto pay FULL cost Please fax Financial Declaration and Supporting Documents to: 406-496-3872 Montana Chemical Dependeney Center Attention: Peggy Bennetts S525 E. Mercury Butte MT 59701