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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
(To be completed and signed by licensed professional provider who has access to individual’s psychiatric records.)
New Member Data Name:___________________________________ Address:_________________________________ _________________________________________ E-mail:___________________________________
DOB: Month/Year______ /______ /_________ |
Referral Source Name/Title:_______________________________ Agency:__________________________________ Address: _________________________________ Tel:_____________________________________ Email:___________________________________ |
Reason for Referral: _________________________________________________
________________________________________________________________
Database (for Point After use) Entered on _____/______/______ |
________________________________
Signature:
Revised March 2011
REQUESTED INFORMATION
Name of prospective member: _______________________
Current psychiatric diagnosis (please include DSMIV Axis Code numbers, name and date
of diagnosis): ____________________________________________________________
Secondary Diagnosis: ____________________________________________________________
Does referee have any medical, physical or communication problems, which may affect his/her participation in the Program? : Yes _______ No_______ if yes, please comment: _____________
Please list recent or present treatment programs: _______________________________________
______________________________________________________________________________
Does referee have a history of substance abuse? Yes _______ No _______ if yes, please
Comment: ______________________________________________________________________________
Legal History: (Arrest, probation, custody, guardianship, restraining order etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Based on my knowledge of this person and a review of the club’s safe community policies, he/she does not pose a threat to the Point After Club Community:
Agree _______ Disagree_______
Signature ________________________ Date _______________________
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.
8. No soliciting is permitted. Anyone interested in selling items or services must obtain the approval of the General Membership. These Policies have been adopted by the membership of the Point After Club to govern the operation of the club, and to protect Club members and staff members from improper behavior or activities of other club members and visitors. Failure to abide by these policies may be grounds for suspension. Member Signature: ____________________________
|
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 to determine eligibility, and enhance prospective new members participation
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
INFORMATION TO RELEASED FROM FOLLOWING AGENCY/INDIVIDUAL;
(include address)
__________________________________________________________________________
__________________________________________________________________________
DATE OF REQUEST___________________
SIGNATURE OF MEMBER______________________________________________
SIGNATURE OF STAFF AND TITLE______________________________________