CMC Weekend Program PO Box 816 Wilder, VT 05088
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- Laurence Nelson
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1 CMC Weekend Program PO Box 816 Wilder, VT Enclosed is the registration paperwork required for registration (State of Vermont Registration form, State of Vermont Release of Information form, CMC Intake Questionnaire and Physical Examination form) into the Weekend CRASH Program at the Hotel Coolidge at 39 Main Street in White River Jct, 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 or Paypal, a link to pay via paypal is on the Please make money order payable to: the Clara Martin Center. In order to participate in the weekend program, we must have a signed physical examination form from your Doctor stating that you are medically cleared to attend the program. Enclosed is a physical form, although your doctor may choose to use a similar form. Your physical does not have to be completed to register, but you must have a physical that is no older than 90 days, prior to attending the Weekend CRASH Program, any physical exam older than 90 days will not be accepted. 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. NO REFUNDS WILL BE ISSUED FOR THOSE PARTICIPANTS NOT HAVING A PHYSICAL. The Weekend CRASH Program is held at the Hotel Coolidge at 39 Main Street in White River Jct, VT. The program begins at 3:30 PM on Friday of the scheduled weekend. You are responsible for arranging transportation to and from the program. The CMC Weekend CRASH 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 Hotel Coolidge (802) provides rooms at a discounted rate of $84.00 per night (for 1 or 2 people). When making reservations just ask for the Rest Easy Rate through the Clara Martin Center/Weekend CRASH Program (the Hotel Coolidge ONLY accepts credit cards to make a reservation). Cancellation Policy: There is a 48 hour cancellation policy. If you cancel prior to 48 hours you are eligible for a full refund, 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. In order to attend a future weekend, you must pay an additional registration fee of $ According to State requirements you may be required to attend further counseling. For first offenders, this treatment program must consist of a minimum of 6 hours and 4 sessions, and they must continue over a minimum period of 4 weeks. Second offenders are mandated to attend a minimum of six months and at least 20 sessions of alcohol/drug treatment. If you have further questions, please call (802) 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 CRASH 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 PAYPAL there is a link to the PAYPAL option on our website (All other forms of payment will be returned to you with your registration paperwork.) Make money orders Payable to: CLARA MARTIN CENTER Your physical does not have to be completed to register, but you must have a physical no older than 90 days prior to the date attending the Weekend CRASH Program. 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. NO REFUNDS WILL BE ISSUED FOR THOSE PARTICIPANTS NOT HAVING A PHYSICAL. Registration is on a first come, first serve basis. Meaning we receive your money order, the following 3 forms completely filled out and we will then register you for the next available CRASH Weekend. We will in turn mail you a confirmation letter with your scheduled weekend and directions to the Hotel Coolidge. 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. CMC 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 you are eligible for a full refund, 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. In order to attend a future weekend, you must pay an additional registration fee of $
3 STATE OF VERMONT PROJECT CRASH EDUCATIONAL PROGRAM RULES WEEKEND PROGRAM OBJECTIVES OF THE CRASH 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 CRASH 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 CRASH Educational program is required. Come to session on time. Tardiness will result in being dismissed from this course. A new registration for another CRASH Educational program would be required. Attend 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 CRASH Educational Program is 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. FEES and REGISTRATION A fee of $ is due upon registering for the CRASH Educational Program. Payment by money order or Paypal, link to pay via paypal is on the Physical exam must be received by the Clara Martin Center at least 2 weeks prior to the beginning of the class. 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 CRASH Educational Program, no monies will be refunded. However, the individual may register into a second CRASH Program, at an additional $500 fee. Failure to satisfactorily complete a second CRASH Educational Program will require an additional registration with another full payment of $ Cancellation Policy: There is a 48 hour cancellation policy. If you cancel prior to 48 hours you are eligible for a full refund, 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. In order to attend a future weekend, you must pay an additional registration fee of $ NOTE: A physical exam is required in order to attend the Weekend Program. This needs to be received prior to your attendance in the weekend program.
4 STATE OF VERMONT PROJECT CRASH REGISTRATION FORM WEEKEND EDUCATIONAL PROGRAM To register for the Project CRASH 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: Clara Martin Center Weekend CRASH Program PO Box 816 Wilder, VT Date of Class: Your Name (Please print): Date of Birth: 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 CRASH 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 CRASH Educational Program. Name: Date:
5 CONSENT FOR THE RELEASE OF INFORMATION I,, date of birth: / /, authorize Project CRASH to disclose information about the facts of my enrollment, current status, and completion of the Project CRASH School/therapy program to, and to obtain information to assist in determining completion of the Project CRASH School/therapy program from: The Vermont Department of Motor Vehicles, The Vermont Department of Corrections, including Probation & Parole, Applicable Vermont District or Superior Court(s), Please check any additional agencies/persons to whom information may be disclosed and received: Spouse and/or other family member (MUST list names) Attorney (MUST give name or agency) Department of Motor Vehicles in a State other than Vermont (MUST give department and address) Counselor/Treatment facility (MUST give name of facility and/or counselor) Other agency or person The purpose of the disclosure authorized herein is to: Satisfy the conditions of my probation/parole and/or Satisfy conditions for the reinstatement of my driving privileges and/or Other. I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically upon my release from probation/parole and upon reinstatement of my driving privileges. Signature of Participant: Date:
6 CMC WEEKEND PROGRAM INTAKE QUESTIONNAIRE Weekend you wish to attend Name (exactly as it appears on drivers license) StreetAddress City State Zip Phone # Please circle one: Male or Female Date of birth Height Weight 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 CRASH 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.
7 In order to participate in the weekend program, we must have a signed physical examination form from your Doctor stating that you are medically cleared to attend the program. This has to be completed by your Doctor within 90 days prior to CRASH weekend class, any physical exam older then 90 days will not be accepted. Enclosed is a physical form, although your doctor may choose to use a similar form. The physical form must be in our possession 2 weeks prior to the weekend you are attending. You can either fax (802) or mail it to us: Clara Martin Center, PO Box 816, Wilder, VT Failure to submit your physical examination form by the deadline will result in your inability to attend the confirmed weekend. Placement will then be based upon the next available date.
8 Clara Martin Center s Weekend CRASH Physical Examination Please fax to or mail to PO BOX 816, Wilder, VT Participant s Name Date of Examination: DOB: Age Height Weight General: Appearance (Dress, Cleanliness,etc) Blood Pressure Resp. Rate /min Pluse Reg Irreg Explain Behavior YES NO Explain Anxious Irritable Uncooperative Hyperactive Alcohol on Breath Dermatology Vascular Dilitation Clubbing/Edema Dupuytrens Contractures Rhinophyma Palmar Erythema Cigarette Burns Spider Nevi IV drug needle marks Other Burns/Scars not from surgery? Where? HEENT Evidence of Head Trauma Extraocular Movements: Intact Not/Explain Pupil Size PERRLA? Not/Explain Sclerac: Clear Icteric Nasal Septum: Intact Not/Explain Periodontal Disease Yes No Swollen Parotids Yes No Chest Gynecomastia_ Lungs: Clear to A&P Duliness Rales Rhonchi Wheezes Heart: PMI: quality and location Rhythm REG IRREG explain Sounds S1 S2 Others(S3.S4. Rubs. Gallops) Murmur (Describe if Poss.)
9 -2- Abdominal Exam Tenderness (location) Ascites Bowel sounds(+/-) Masses Liver cm Palpable? Splenomegaly Neuropsychiatric Cranial Nerves Intact? Not/Explain Cerebellar: Tremor Tandem Walk F to N Romberg+/-? Extremities: sensory (upper+lower)intact symmetrical Motor (upper+lower)intact symmetrical Deep Tendon Reflexes: Cognition: Object Retention /3@ min World---à,ß---- Serial Sevens ASSESSMENT Problems Associated with Alcohol Use or Drug Use: Other Problems: Examiner s Name Examiner s Signature PLEASE INCLUDE EXAMINER S ADDRESS Phone: Date: (in part) Dartmouth Hitchcock Weekend Impaired Drivers Intervention Program (WIDIP), Project Cork Institute, Dartmouth Medical School, Hanover, NH Used by permission
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Dr. Kristin Heins, ND Thrive Natural Family Health 110 Eglinton Avenue East, Suite 502 Toronto, Ontario M4P 2Y1 Telephone: (647)
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Please allow us hours to refill the medication; approval from your medical provider is required on all refills.
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Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:
Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married
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We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal.
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Patient Information Form
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