Initials of State and Out of State DL # Complete as Applicable
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1 Bridgeway Center Inc. Community & Court Education Services Enrollment Form Have you ever attended any classes at Bridgeway Center, Inc.? Yes No Today s Date First Name Middle Name Last Name / / Address City State Zip Home Phone Work Phone Cell Phone Emergency Contact Phone Emergency Contact Person Emergency Contact Address or Relationship Social Security # Sex / / Male Female Date of Birth Please Circle Marital Status Race Education Married Asian 8 th Grade or Less Never Married Black Some High School Divorced Hispanic GED Widowed Native American HS Graduate Living Together White Some College Separated Other Tech/Business Other College Grad Professional Grad Job/Occupation County of Home or Work How did you Hear of Our Program? (Please Circle) Attorney DHSMV Order Court Order Friend Law Enforcement Officer Mailer Insurance Company Other Disability F L Place of Employment - Florida Driver License # Initials of State and Out of State DL # Complete as Applicable Charge Court Date Case # Arrest Date (Citation Date) Judge County & State of Arrest or Citation Probation Officer Probation Officer Phone # and Address
2 Bridgeway Center INC. Driving Schools DUI SCHOOL DRUG ALCOHOL TRAFFIC EDUCATION C.A.S.E. DRIVER IMPROVEMENT MONEY MANAGEMENT SUBSTANCE ABUSE COURSE REGISTRATION QUESTIONNAIRE 1. NOT INCLUDING THIS ARREST, have you ever had a substance use related arrest anywhere at anytime (whether or not you were convicted)? YES NO 2. Have you ever attended a Substance Abuse Course anywhere at anytime? YES NO If yes, where & when? 3. Were you arrested (this arrest) in Okaloosa County, Florida? YES NO (If NO, name the other county (and state, if not in Florida) and complete the form requesting a copy of the arrest report. 4. In what county do you live /work? 5. How much responsibility do you feel you should take for the events that led to this arrest? No responsibility at all Little responsibility Some of the responsibility Most of the responsibility All of the responsibility 6. Do you think it was fair for you to be arrested for this charge? Not at all fair Slightly fair Somewhat fair Mostly fair Entirely fair **PLEASE ANSWER QUESTIONS ON THE OTHER SIDE**
3 7. Please list ALL of your arrests, including this one (please include as much information as possible, such as dates, the charge, breath test results (BAC), and whether or not you were convicted). 11. Please list any prescription medication you are taking: 12. Have you ever had a seizure? No Yes Explain: Do you have diabetes? No Yes Explain: Do you have a heart condition? No Yes Explain: Do you have any allergies that may result in an emergency (foods or medications)? No Yes Explain: Do you have any other medical problems that may result in an emergency situation? If yes, please explain. **I certify by my signature that the aforementioned information is correct.** Signature / / Date
4 Driving Schools Service Policies & Client Responsibilities Service Policies & Client Responsibilities As a client of Bridgeway Center, Inc., you are entitled: 1. To be treated courteously, with dignity and respect. 2. To be given essential information about: a. The person(s) responsible for your services, their professional qualifications and their specific qualifications to provide the services you receive. b. The results of your evaluation. c. If referred for counseling, the list of approved treatment providers; you will be free to choose one of the providers on the list. 3. To refuse service at any time without penalty. However, if you have been ordered to service by the court or law enforcement, you will be informed of the consequences of your refusal. 4. To have all service kept confidential, within the law. The law requires that if you are in clear and imminent danger of suicide or a threat to others, your counselor must communicate with the proper authorities and individuals. Bridgeway Center DRIVING SCHOOLS must surrender with or without your consent, records lawfully requested. Under the law, certain Department of Children and Families authorities have the right to check Bridgeway Center records. 5. To be informed of your rights and responsibilities, assistance to reasonably exercise your rights, and to use our complaint/appeal system for the resolution of conflicts. Please ask anyone at Bridgeway for a list and description of your rights. We have, also, located copies of the Department of Children and Families poster entitled Know Your Rights throughout our facilities. Bridgeway will be responsive to your concerns; please help us by completing our satisfaction surveys when asked to do so. A few of your responsibilities as a client include: (You have to be honest with us and follow our rules, and we expect you to participate in services.) 1. Open and honest communications with the Bridgeway Associates serving you. 2. Completing the schedule you have been assigned or calling and rescheduling within the specified time frame. 3. Pay any additional fees you incur at the time they are requested. Daniel Cobbs, MPA, CHE Chief Executive Officer HIV Policy Statement (HIV/AIDS affects the body s ability to fight off infections. Because alcoholics and addicts may be involved in casual sex or share needles, they are more likely to have HIV/AIDS. Recent weight loss, tired easily, short of breath, body aches or having sores are all symptoms of HIV/AIDS. If you are shooting drugs, you should stop immediately and complete treatment. We can evaluate you and if you have a contagious disease, and if you want us to, we will help you find counseling or treatment for that disease. We will not discriminate against you or refuse you treatment because of any contagious disease.) As client of Bridgeway Center, Inc., you must understand that Bridgeway accepts and will not discriminate against HIV Positive persons for mental health and alcohol/drug abuse treatment and will not discriminate against employees or in its hiring practices against a HIV positive person. Any knowledge of the presence of the virus will be handled with confidentiality in accordance with federal and state laws and to the degree clinically practical. You will have the opportunity to ask questions regarding these issues and HIV-related risks involved. You must understand that infringement of program rules, i.e., sex on premises, drugs on premises and violent behavior, can place you at risk for infection from communicable diseases to include hepatitis, gonorrhea, syphilis or HIV. NOTE: There are two recommended sources for assistance and information outside of Bridgeway Center: (1) AIDS HOTLINE FLA-AIDS and (2) Department of Children and Families County Public Health Units which provide confidential and anonymous testing, and who also distribute AZT, a life prolonging drug. Complaint/Grievance System If any issue is not satisfactorily resolved or explained, you may address your concerns to management staff: Program Manager ( x 203) Quality Performance Services Program Director ( ) Last Modified 01/23/2008 DRIVING SCHOOLS
5 2 Chief Executive Officer ( ) Any issue submitted in writing will be responded to in writing within 5 business days. This process does not supersede the right of a patient to file a complaint with external agencies such as: Depart. Of Children & Families Program Office (850) Upon request, DRIVING SCHOOLS staff will assist clients with contacting the external agency of their choice. It is the intent of the DRIVING SCHOOLS to provide quality and caring services; the complaint system is designed to further this objective. Please share with us any issue that you feel is contrary to this goal. Confidentiality Issues Records may not be disclosed without the written consent of the client to whom they pertain except under the following conditions. a. To medical personnel in an emergency; b. To the other service provider personnel only if such personnel need to know the information in order to carry out duties relating to the provision of services; c. To the secretary of the department or his/her designee, for purposes of scientific research, in accordance with federal confidentiality regulations, but only upon agreement in writing that the patient s name and other identifying information will not be disclosed; d. During the course of review of records on DRIVING SCHOOLS property by persons who are performing an audit or evaluation on behalf of any federal, state, or local government agency, or third-party payer providing financial assistance or reimbursement to Bridgeway Center, Inc.; e. Upon court order based on application showing good cause for disclosure; f. Restrictions do not apply to communications between DRIVING SCHOOLS staff and law enforcement officers which; (1) are directly related to a patient s commission of a crime on Bridgeway Center property or against staff or to a threat to commit such a crime; and (2) Are limited to the circumstances of the incident g. Restrictions on disclosure and use do not apply to the reporting of incidents of suspected child abuse and neglect or abuse of an elderly or disabled adult to the appropriate state and local authorities as required by law. h. Any answer to a request for a disclosure of patient records, which is not permissible under Ch Florida Statute, or under the appropriate federal regulations, must be made in a way that will not affirmatively reveal that an identified individual has been, or is being diagnosed or treated for substance abuse. This does not restrict a disclosure that a patient is not and never has been a patient. Medical Emergencies In case of an emergency, staff is trained to function as First Responders. This means that appropriate basic first aid (to include CPR) will be administered upon the discovery of a medical emergency. DRIVING SCHOOLS Representative Date Client Signature Last Modified 01/23/2008 DRIVING SCHOOLS
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