Point After Club
43 Jackson Street
Lawrence, MA 01840
Tel: 978-681-7753
Fax: 978-725-5527

pointafter1@yahoo.com


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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:_________________________________

_________________________________________

_________________________________________

Tel:______________________________________

E-mail:___________________________________

 

 

DOB: Month/Year______ /______ /_________

Referral Source

Name/Title:_______________________________

Agency:__________________________________

Address: _________________________________

Tel:_____________________________________

Email:___________________________________

Today’s date: _______/_______/_________

 

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.
  • 1st offense: a warning
  • 2nd offense: 1 day suspension
  • 3rd offense: 1 week suspension and policy hearing
  • 4th offense: 60 days suspension

8. No soliciting is permitted. Anyone interested in selling items or services must obtain the approval of the General Membership.
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. Smoking is not allowed in the building or on the club entrance on Garden Street.

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: ____________________________
Staff Member Signature:_________________________ Date: _____________________

 

 

 

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


paclogo

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______________________________________

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