Northeast Kingdom Human Services Impaired Driver Rehabilitation Weekend Program

Transcription

1 Northeast Kingdom Human Services Impaired Driver Rehabilitation Weekend Program Enclosed is the registration paperwork required for registration (State of Vermont Registration form, State of Vermont Release of Information form, NKHS Intake Questionnaire and Physical Examination form) into the Weekend IDR Program at the Northeast Kingdom Human Service Building at 2225 Portland Street, St Johnsbury VT In order to be registered into the program you must complete and return the registration forms, all forms MUST be filled out with your name as it appears on your license; Payment needs to be made by money order. Please make money order payable to: Northeast Kingdom Human Services. The physical paperwork (included in this packet) must be in our possession 2 WEEKS before your scheduled weekend or you may be cancelled out of the class. The Weekend IDR Program is held at the Northeast Kingdom Human Services building at 2225 Portland Street, St Johnsbury VT. The program begins at 3:00 PM on Friday of your scheduled weekend. You are responsible for arranging transportation to and from the program. The NKHS Weekend IDR Program is NOT a residential program. If you need to stay over, you will be responsible for making your own hotel reservations and paying for those separately. The Comfort Inn in St. Johnsbury (802) provides rooms at a discounted rate (for 1 or 2 people). When making reservations just ask for the IDRP rate through NKHS. Comfort Inn only accepts credit cards to make reservations. Cancellation Policy: There is a 48 hour cancellation policy. If you cancel prior to 48 your refund will be determined by what services you have already received, or you can be moved to a class at a later date. If you cancel within 48 hours, you are NOT eligible for a refund. According to State requirements you may be required to attend further counseling. For first offenders, this treatment program must consist of a minimum of 4 hours, 4 sessions, over a minimum period of 4 weeks. Second offenders are mandated to attend a minimum of 20 sessions over a minimum of 24 weeks, with a Licensed Alcohol and Drug Counselor If you have further questions, please call (802) , Ext, 1194 or fax (802) Sincerely, The Weekend Program Staff PLEASE NOTE: This program is for people with DUI #1 and DUI #2 only. If you are being charged with 3 or more DUI s you are not eligible for the Weekend Program. Please contact Project IDRP at (802) for more information.

2 IMPORTANT INFORMATION PLEASE PAY CLOSE ATTENTION TO UNDERLINED AND/OR BOLD PRINT AREAS THROUGHOUT THE PACKET Please use the following guidelines to expedite the registration process: Payment in the form of a MONEY ORDER or Cashier s Check (All other forms of payment will be returned to you with your registration paperwork.) Make money orders Payable to: Northeast Kingdom Human Services The paperwork (included in this packet) must be in our possession 2 WEEKS before your scheduled weekend or you may be cancelled out of the class. Registration is on a first come, first serve basis. Meaning when we receive your money order, the following 3 forms completely filled out and we will then register you for the next available IDRP Weekend. We will in turn mail you a confirmation letter with your scheduled weekend and directions to NKHS. These forms must accompany the money order: FORMS MUST BE FILLED OUT WITH FULL LEGAL NAME AS IT APPEARS ON YOUR LICENSE: 1. State of Vermont Registration Form 2. NKHS Intake Questionnaire 3. State of Vermont Release of Information Form Cancellation Policy: There is a 48 hour cancellation policy. If you cancel prior to 48 hours your refund will be determined by what services you have already received, or you can be moved to a class at a later date. If you cancel within 48 hours, you are NOT eligible for a refund.

3 STATE OF VERMONT PROJECT IDRP EDUCATIONAL PROGRAM RULES WEEKEND PROGRAM OBJECTIVES OF THE IDRP EDUCATIONAL PROGRAM: To provide you education about alcohol use and its effects on you and the community. To provide you with the opportunity to examine your own drinking and driving behavior. To inform you of the resources available to assist you in changing your drinking behavior if You find you need or want to. RULES AND REQUIREMENTS OF THE IDRP EDUCATION PROGRAM ARE: Arrive promptly on Friday afternoon for screening and intake sessions. Attend all sessions. An absence during a session, will be considered a drop and will result in being dismissed from this course. A new registration for another IDRP Educational program will be required. Come to session on time. Tardiness will result in being dismissed from this course. A new registration for another IDRP Educational program would be required. Attend the program alcohol and drug free. Any evidence of the use of substances prior to or during the program will result in immediate dismissal from the course, and a registration for another IDRP Educational Program will be required. Active participation in session discussion (as determined by group leaders) will be required at all sessions. A satisfactory plan to avoid future occurrences of driving under the influence of alcohol or drugs will be developed by the individual and presented at the final session for review by the group leaders, then again at the exit interview. Attend an exit interview following the completion of the weekend. CONFIDENTIALITY IS A MUST.

4 FEES and REGISTRATION A fee of $ is due upon registering for the IDRP Educational Program. Payment by money order or cashier s check only. Registration and payment should be sent as soon as possible to ensure enrollment in the first weekend available. Registrations will be processed as they are received. Upon receipt of payment, you will be registered into the next available class; the program is run on a first come first serve basis. If an individual fails to successfully complete the IDRP Educational Program, no monies will be refunded. You may register into a second IDRP Program, at no additional cost. Failure to satisfactorily complete a second IDRP Educational Program will require an additional school fee of $ Cancellation Policy: There is a 48 hour cancellation policy. If you cancel prior to 48 hours your refund will be determined by what services have already been provided, or you can be moved to a class at a later date. If you cancel within 48 hours, you are NOT eligible for a refund.

5 STATE OF VERMONT PROJECT IDRP REGISTRATION FORM WEEKEND EDUCATIONAL PROGRAM To register for the Project IDRP Educational Program you must fill out the following information and return this form, at least two weeks prior to the beginning of the School, to: Northeast Kingdom Human Services Weekend IDRP Program PO Box 368 St. Johnsbury, VT Date of Class: Your Name (Please print): Date of Birth: As it appears on your license Address: Telephone Number :( Day) (Evening) Total Number of Alcohol Related Driving Offenses: License Number (if available) Reason Attending this School: First DWI in Vermont Second DWI in Vermont Civil Suspension in state of Court/Probation ordered in state of DWI in another State: Date(s) State(s) Other in state of Education: Less Than High School High School Some College College More Than College Marital Status: Single Married Divorced/Separated Significant Other Other Employment Status: Unemployed Employed, Number of years Any disabilities that Project IDRP should be aware of? No Yes If yes, please list any assistance or assistive devices that you may need: I hereby acknowledge receipt of a copy of the rules and requirements of the Project IDRP Educational Program. Name: Date:

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7 NKHS IDRP WEEKEND PROGRAM INTAKE QUESTIONNAIRE Name (exactly as it appears on driver s license) StreetAddress City State Zip Phone # Please circle one: Male or Female Date of birth Occupation How long? Present Marital Status: (circle one) Single Married Separated Divorced Widowed Do you have children? How many? Do they live with you? Emergency contact person Phone # NAME AND ADDRESS OF FAMILY PHYSCIAN: Have you ever been hospitalized? Have you ever had a serious injury? If yes, please explain Do you have any medical problems (heart, diabetes, seizures, etc)? Please list any medications taken in the last year Please list medications you will be bringing to the IDRP program and the doctor who prescribed them Do you use alcohol now? Have you ever attended AA and/or NA? Do you currently attend AA and/or NA regularly? Personal information (How many DUI s, reason for entering program, living situation, treatment programs, etc), use back of form if needed.

8 Northeast Kingdom Human Services is committed to and responsible for protecting the privacy of your health information. The information we ask from you on the front of this form will help us to fulfill this responsibility. Name of person whose information is being requested: This is the name of the person that the Agency has provided services to and is keeping information on. This should not be confused with the individual or an individual's parent/guardian. Birth Date: Along with your name we use your birthday as a means to identify you. On occasion we may ask for more information such as your social security number. We do this because some names are common and birthdays and social security numbers can be used to identify the right person. Name and address of person/agency making the disclosure: This is the organization or person you are asking to disclose information about you. In most cases this will be the Agency but we could be asking for information from another provider. Be sure to include the address or we will not know where to send it. Name and address of person/agency receiving the disclosure: We are asking who and where you want us to send the information. If the Agency is requesting the information then our name and address will be listed here.. Date or event upon which this authorization will expire: This authorization will automatically expire a year from the date you signed it unless you tell us an event or other date when it should end. Signatures: In order for the Agency to honor your request, the authorization form must be signed by you if you are an adult or an emancipated minor. If you are an adult but have a legal guardian or representative they must sign this form. If you are under 18 years of age your parent/guardian must sign for you. However, if you are a minor who is 12 years of age or older and sought confidential drug/alcohol treatment under a physician's care then only you can sign this form not your parents or guardians. The Agency requires a copy of guardianship papers or documentation of legal representation in order to honor a release from a guardian or legal representative. All signatures must be dated. In order to protect your information we may ask you to provide identification to make sure you are you. Revoking Authorization: If you decide to change your mind about disclosing this information you can, in the future take back your authorization. Call or stop in to complete this section. This change would only stop future disclosures and sharing of information, but does not apply to past disclosures. Please make sure you fill in the entire form. Failure to fill in all of the information, as described above, will result in an invalid authorization and the Agency will be unable able to fulfill your request.