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Point After Club |
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POINT AFTER CLUB 43 Jackson St. Lawrence, MA 01840
(978) 681-7753
REFERRAL FORM
(The Following questions are to be completed before referree can be considered for club membership)
Person being referred:_________________________________________________________Date:______________
Adress:___________________________________________________________Telephone:___________________
City:_______________________________________State:________________Zip:_________D.O.B.____________
Refering Staff:_______________________________________________Title:_______________________________
Agency:___________________________________________________________Telephone:___________________
Address:____________________________________City:__________________State:_________Zip:____________
If referal DMH
Eligible_________Yes______No_______Explain_______________________________________________________
Reason for Referal:
Current psychiatric diagnosis(es). (Please include DSM IV Axis code numbers, name and date of diagnosis).
Does referee have a history of substance abuse? Yes_____No_____If yes, please comment.
Having read the policies of the Club, pleasestate wheater, in your opinon referee would have difficulty abiding by them.
Yes______No______If yes please comment.
Does referree have any medical, physical, or communication problems that may affect her/ his participation in the program? Yes_______No______If yes, please describe;
Point After Club
| Policy: Safe Community Rules and Regulations |
| 1. Respect for other members and staff members is expected all all times. 2. Illegal drugs and alcohol are prohibited! Any member who is under the influence of illegal drugs or alcohol will be asked to leave the premises. 3. Property damage or the theft of personal or clubhouse property will result in immediate suspension and possible prosecution to the fullest extent of the law. 4. Violence of any sort will not be tolerated! 5. Sexual harassement is not tolerated. All individuals need to respect each other's bodies and personal space. Unwanted affectino is not accepted and individuals should be clear in their communication regarding this. 6. Obscenitites in either gesture or language will not be tolerated. 7. Members are expected to take care of their own individual needs. Harassing others for Cigarettes, Money etc. will not be tolerated and will be cause for suspension.
9. Members are not allowed in unauthorized areas of the building. The Club leases space on the first floor, which includes the main clubroom, the buisness office and the employment/housing unit areas, and in the basement including the Campbell Center and the kitchen. All other areas are off limits exept fro when members are walking through to club leassed space or the rest rooms. 10. Smokin g is not allowed in the building or on the club entrance on Garden Street. |
BASIC AND EMERGENCY INFORMATION
The informatin on this form is confidential and is for staff use only, except in the case of emergency:Point After Club Start Date______________Renewal Date____________
MEMBER NAME:________________________________________________
Address:_______________________________________Telephone:________________________
City:_______________________________State__________Zip:___________DOB:____________
Primary Unit:_______________________________________Staff Advocate:__________________
Landlord Name:__________________________________Telephone:________________________
MEDICAL INSURANCE:
MassHealth#:____________________________________Medicare:_________________________
BC/BS, Medex, HMO, etc__________________________________#_______________________
DO YOU RECEIVE DMH SERVICES: YES_________NO_______
IF SO, DMH PRIMARY PROVIDER:_______________________________________________
Agency:_______________________________Title:_______________________________________
Address:_____________________________________________Phone:_______________________
EMERGENCY CONTACT (family Member or Significant Other)
Name:___________________________________________________Phone:___________________
Relationship:________________________Address:________________________________________
City:______________________________State:____________________Zip:____________________
PRIMARY PHYSICIAN:________________________________________Phone:______________
Address:_______________________________________________________Phone:______________
City:_______________________________State___________________Zip:_____________________
CRITICAL MEDICAL
INFORMATION__________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
PRIMARY THERAPIST:_________________________________________Phone:_____________
Agency:_____________________________________Address:_______________________________
City:________________________________________State:_______________Zip:_______________
PRIMARY
PSYCHIATRIST________________________________________________Phone:______________
Agency:______________________________________State:______________Zip:________________
City:_________________________________________Address:___________Zip:________________
Do you take psychiatirc or other medication? Yes_______No_______
Name, Agency, and phone number of prescribing physicain for psychiatric medications:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Name, Agency, and phone number of prescribing physicain(s) for other medications:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have any children? Yes______No_____
If yes, how many___________ages________
What is their custody status?
_________living with me
_________unsupervised visitation
_________supervised visttion
_________no visitatino
_________Other
Any changes in the above information, please notify your Staff Advocate.
Member Signature:_____________________________________________Date:______________
Staff Member Signature:_________________________________________Date:______________
Revised June 2010
43 Jackson Street
Lawrence, Massachusetts 01840
(978) 681-7753
REALEASE OF INFORMATION
INFORMATIONAL RELEASE AGREEMENT
Member's Name:________________________________________________________________
Date of Birth:__________________________
I herby authorize the staff of _____________________________________________________
to release the information specifically requested below to the Point After Club. I understand that this is completely voluntary on my part and I release the agencies and/or individuals from any liability arising from the release of this information. I understand that this consent is subject to revocation by my request at any time, unless the action based on it has already begun. This request expires 90 days from the date signed by member.
INFORMATION TO BE RELEASED
information needed by the Point After Club to complete Basic Emergency Fact Sheet
DATE OF REQUEST___________________
SIGNATURE OF MEMBER______________________________________________
SIGNATURE OF STAFF AND TITLE______________________________________