Microsoft word - residential application 2011 _2_.doc

A Non-Profit Corporation
Dedicated to Promoting Individual, Family and Community Wellness Through a Variety of Substance Abuse and Thank you for requesting information about New Frontier Treatment Center. New Frontier (NFTC) would like to take this opportunity to inform you of the variety of programs and individual treatment plans we offer to help meet your special needs. Whether this is your first attempt at change or you are a veteran of a previous rehabilitation program we believe that our program can be of great help to you. Our professional staff and peers are available to help you achieve this goal. All agency programs are state licensed and accredited. Listed below are the residential services offered at New Frontier Treatment Center. Level III.2D – Social Model Detox – NFTC can admit detox clients into services Monday thru
Sunday 24 hrs. Detox screening may take place over the telephone or face-to-face in the case of
a “walk-in”. The maximum capacity for detox services is 2 males or 2 females. Medical
clearance will be required before a client can be admitted. Client is responsible for any
prescribed medication.
Level III.3 - Clinically Managed Medium Intensity Residential Treatment – How long does
residential care last? The programs at New Frontier Treatment Center are not defined by a
number of days, but rather by individual needs. Lengths of stay for the residential program are
dependent on the needs of the individual and are determined through an assessment process.
Successful treatment is the ultimate goal, and time is necessary to triumph the battle. The first
week is an assessment period to determine if residential and any other services are needed by the
client. If New Frontier Treatment Center determines that residential services can be provided,
then the client will be re-evaluated each week to determine treatment progress. Clients will be
attending group sessions, individual counseling, substance abuse education classes, recreation,
and may be introduced to Twelve Step meetings.
Level III.1 - Clinically Managed Low Intensity/Advanced Recovery Residential Treatment–
this is a less intensive program and is a longer commitment with the possibility of up to six
months depending on client’s need. Clients in this program have successfully completed the
medium intensity residential program. Clients in the program are required to fill out a daily goal
plan to let staff know their whereabouts throughout the day and obtain approval from staff.
Clients are required to follow their schedule explicitly, find employment within one
week of entering this level of treatment, attend weekly inpatient meetings, obtain a sponsor
within one week of entering this level, attend group sessions and individual counseling, and
maintain a clean living environment. Clients in Level III.1 residential treatment pay weekly on
their treatment bill, which varies depending on client’s income level
_____________________________________________________________________________________________
OFFICE LOCATION
ADMINISTRATION
BOARD OF DIRECTORS
1490 Grimes Street Lana Henderson, Executive Director Jim Wood, Chairman Vaughna Bendickson, Vice-Chairman Fallon, NV 89406-2919 Mandy Rigsby, Clinical Director Joe Lane, Treasurer Ron Marrujo, Member Ph: (775) 423-1412 Valerie Pacheco, Operations Manager James Richardson, Member Susan Chambers, Member Fax: (775) 423-4054 Debbie Ridenour, Human Resources ADULT RESIDENTIAL SERVICES  ADULT & YOUTH OUTPATIENT SERVICES  ALCOHOL & DRUG EVALUATIONS New Frontier’s fees are based on a sliding scale so that all clients entering our programs
regardless of income can afford treatment. New Frontier Treatment Center’s program requests a
housing fee according to the SAPTA sliding fee scale schedule. All clients being admitted for
residential treatment are drug tested at time of arrival and there is a $35.00 UA/BA fee and
$75.00 for a physical. Unless other arrangements have been made with the financial department,
these fees will be requested at admittance. New Frontier Treatment Center now has the
capability to accept Nevada Welfare Quest Card, Visa or MasterCard to pay for treatment costs.
In some instances private insurance may cover a portion of residential services. Unfortunately,
Medicare does not cover residential services. Verification of income must accompany
completed Inpatient Application.
New Frontier Treatment Center is also a non-smoking, tobacco-free facility. The use of tobacco
products is prohibited in or on New Frontier’s property. The suggestion is to become tobacco
free for 72 hours prior to admit. In addition, New Frontier Treatment Center offers help with
those who wish to stop using tobacco products. Our nicotine dependence program including
pharmacotherapy’s is available to all residential clients.
Enclosed you will find a copy of New Frontier Treatment Center application. Please complete
the following forms and either fax or mail the completed application to the Intake Department at
the number or address listed below. ** Incomplete applications will not be accepted.


MAIL/FAX TO: Intake Department/Residential Treatment
The Intake Department will contact you after your application has been received. If you do not receive a call within 5 days, please call to check on the status of your application. If you have any further questions, please do not hesitate to contact New Frontier during business hours of 8:00 a.m. – 5:00 p.m. Monday-Friday at (775) 423-1412. Sincerely, New Frontier Administration 1490 Grimes Street
Fallon, Nevada 89406
Ph : (775) 423-1412 or 1 (800) 232-6382 Fax: (775) 423-4054

Office Use Only:
Date Application Received: _________ Admission Date: ___________ Client NHIPPS No._________
APPLICATION
*All information must be completed in order for application to be processed*
Personal Information (please print)

____________________________________________________________Date:_____________
Last
Home Address_________________________City________________County_______________ Temporary Address_____________________ City_____________ County_________________ State_________________ Zip_____________ Booking #___________________________________ Prison Back Number:_______________ Home # ( )_________Work #( )________ Message #( )________ Cell#( )_______ Social Security #______________________ DOB: Gender: Male/Female / Transgender: Yes/No

Race: Please circle answer
None Selected / Alaska Native (Aleut, Eskimo, Indian) / American Indian (Other than Alaskan
Native) Asian / Native Hawaiian other Pacific Islander / Black or African White / Other
Single Race / Two or more Races / Unknown

Ethnicity: Please circle answer
Unknown / White (not of Hispanic origin) / Black (not of Hispanic origin) American India/
Alaskan Native / Asian or Pacific Islander / Hispanic-Cuban / Other Hispanic

Religion: None

Mother’s First Name (1st 3 Letters) ____________________________
Client’s Birth City___________________________________________
Caller Identity: Self Family member Friend Employer Other
US Citizen: Yes / No
Veteran: Not a veteran / Vet w/honorable discharge / Vet w/other than honorable discharge
Active Duty / Unknown
Permanent
Contact_______________________________________________________________________
Phone No._____________________________________________________________________
Circle One: Adult or Youth
Health Insurance:
No health insurance /Medicaid/Medicare /Champus/VA / Private w/o Substance Abuse Coverage
CHIPS
/ Private Substance Abuse Coverage Other public funds /health care: ___________________________________________________

Marital / Social History:
Current marital status: ___Married ___Divorced ___Separated ___Single ___Widowed
Pregnant: _________Yes __________No
2. What are your top 3 drug of choice? (Including Alcohol) 4. Are you an I.V. user? ___Y ___N How long have you been an I.V. user? 5. Have you made attempts to cut down or quit before? 6. Are you able to stay clean on your own? 9. Have you experienced medical problems in the past thirty days? ___Y ___N 10. History of DT’s or Seizures? None _____Mild _____Moderate _____ Severe 12. Do you have a history of hallucinations? 13. Do you have any medical issues? ______Yes ______No (Explain) __________________ 14. Any mental health issues? ___Y ___N Diagnosis:_____________________________________ 15. Do you have any physical/mental disabilities that may interfere with treatment or for which you may need special accommodations? ___Y ___N How long have you been taking the medication? If pregnant, have you received medical care including prenatal vitamins? ___Yes __No 17. Medical/Dental appointments scheduled? ___Y ___N List dates: _____________________________________________________________ 18. Current physician’s name and location Indicate if you have had any of the following health problems: Please circle Yes or No Do you have any of the following contagious illness or conditions? Please circle Yes or No Head lice Y/N Other: ________________________________________________________________________ 20. Any history of physical or sexual abuse? ___Yes ___No 21. Any special needs or concerns about writing or reading? ___Yes ___No 22. Have you ever been convicted of a sex crime? ___Yes ___No 23. Have you ever been convicted of a violent crime? ___Yes ___No 24. How long have you been incarcerated? ___________ Reason for incarceration __________ 25. Other Court dates, outstanding warrants, miscellaneous legal information: 26. List names and dates of treatment programs that you have participated in for Residential or Outpatient for substance abuse and/or mental health. Name 27. Do you have any legal issues or court dates? ___Yes ___No Any outstanding Warrants?_________________ 28. Are you ordered by CPS, Court, probation or parole, Counselor, Physician, Social Worker, 29. If treatment is order by the legal system or a local agency, what are the conditions? 30. Please list dates available for treatment. (A.S.A.P will not be accepted as appropriate 31. Are you employed? ____ If yes, employers name________________________________ Address___________________________________ Is your employer aware of your current situation? ______Yes ______No 32. If unemployed, last job held: 34. Any work problems related to reason for admission? ___Yes ___No 35. Have you worked in the last 6 months? ___Yes ___No 36. What is your monthly income amount? 38. Do you have insurance/Medicaid/Medicare/TANF? If yes, insurance: Name_________________Policy number__________________Group number: Smoking /Tobacco Products: Effective July 1, 2002, NFTC is a total non-smoking/tobacco free environment. Waiting List You do have the option of being placed on the waiting list for the next available bed. Please keep in mind that New Frontier Treatment Center uses their priority list to determine who is next in line for the next available scheduling date. To be placed on the waiting list it is mandatory to have a phone number where you or a representative you designate by a signed release can be reached to request placement on the first available bed. Please list first and last name of the person to be contacted is someone other than you. SAPTA (Substance Abuse Prevention Treatment Agency) Defined Interim Services
Please check one of the following:
Pregnant Injecting drug user________ Pregnant Intake staff will contact you after your application has been received. If you do not receive a call within 5 days, please call to check on the status of your application. If you have any further questions, please do not hesitate to call New Frontier during business hours of 8:00 a.m. – 5:00 p.m. Monday-Friday at (775) 423-1412. Residential Client Information Sheet

Processing Information
When submitting your application, the following information will be required to complete the
process:
 Verification of income – pay stub, bank statements, last tax documentation or proof of
income from any agency or local service provider  Referral source name, phone and fax numbers, if available. Due to our limited scope of practice, we request any reports describing the client’s legal history to determine appropriateness for treatment
Payments
At time of admittance:
 New Frontier Treatment Center request that clients being admitted pay the housing fee or
unless other arrangements have been made with the financial department. (Housing fee may be higher depending on income level.)  Drug testing fee $35.00 – UA/BA  Physical fee $75.00  Medication fee $50.00 - $200.00 depending on client’s medical needs.  Payment arrangements will be made for the remaining balances for treatment.  Some insurance companies cover part or all of the costs of treatment at New Frontier Treatment Center. Please call the financial department for further information.  Medicare does NOT cover the cost of residential treatment. New Frontier Treatment Center now has the capability to accept Nevada Welfare Quest Card (Food Stamps), VISA and MasterCard to pay for treatment costs.
Confirming Bed Dates
Clients are required to confirm all bed dates the Friday before check-in. Clients may have
someone confirm on their behalf. Not confirming can result in the loss of the bed-date and the
rescheduling at New Frontier’s earliest convenience.
Admittance
● To be admitted to New Frontier Treatment Center, all clients will be drug tested. Those who
test positive will be screened by the Clinical Director, and if needed, sent to Banner Churchill Community Hospital for medical clearance. Once clearance has been obtained, the client will be admitted either to the social model detox or the residential program.  Clients that are felons are required to register with the local authorities. Please do so prior to arriving at New Frontier Treatment Center.  Be sure to have all prescription medications filled, and have an adequate amount for the duration of your stay. New Frontier Treatment Center staff members are not responsible for payments or filling of prescriptions. No over-the-counter medications will be allowed, and will be confiscated and held in the safe to be returned at time of discharge. Medications that are not allowed to be taken while in treatment include mind/mood altering substances and muscle relaxers. We request that if you are taking any prescribed medication that you are on them at least two full weeks prior to your admittance, and if you have recently stopped taking prescribed medication that you are off them for at least two full weeks prior to admittance. Phone Calls

Clients admitted to New Frontier Treatment Center will be required to have a calling card to
make phone calls, or calls will be made collect. While in treatment, clients will be allowed a
certain amount of phone calls on a case by case basis. In addition client will make one phone
call within 48 hours of admittance and one prior to discharge.
 Clients in treatment are allowed to send and receive mail/letters.  Clients must supply their own stamps and envelopes.
 Care packages are NOT allowed.
New Frontier will not accept any C.O.D. packages or packages with insufficient postage due.

Family Group Counseling

The Family Group Counseling session is held every Sunday from 1:00p.m. to 3:00 p.m. THIS
IS NOT A VISITATION. Children under the age of 13 are not allowed to attend. This is a
time to address any family issues or concerns and to facilitate family involvement.

Visitation
Scheduled visitations are on Sunday from 1:00 p.m. to 3:00 p.m. and are for immediate family
members. Visits by non-family members and visits during non-scheduled days are approved on
a case-by-case basis. The Client Visitation Rules form must be completed by all visitors prior to
any visit.

Physical

Physical examinations are completed within seven (7) days of admission. Clients are requested
to get a physical examination prior to treatment. If a client is incarcerated or due to an
unforeseen circumstance you may make prior arrangements in with New Frontier for your
physical. If a client had a physical examinations within the last 30 days prior to admission this
will be accepted. Any physical given past 30 days prior to admission will not be accepted as a
client’s condition of history changed at the time of admission.

SMOKING POLICY

NEW FRONTIER TREATMENT CENTER IS A NON-SMOKING & TOBACCO-FREE
FACILITY. THE USE OF TOBACCO PRODUCTS IS PROHIBITED IN OR ON ANY NEW
FRONTIER TREATMENT CENTER OWNED/LEASED PROPERTIES (BUILINGS,
VEHICLES, PARKING LOTS, ADJACENT SIDEWALKS AND PROPERTIES.) NEW
FRONTIER TREATMENT CENTER DOES OFFER A SMOKING CESSATION
PROGRAM FOR THOSE NEEDING ASSISTANCE OR YOU CAN CALL THE AMERICAN
CANCER SOCIETY AT (800)227-2345 OR THE RENO OFFICE AT (775)329-0609.
Client are encouraged to bring a supply of nicotine patches, lozenges, and gum during their
stay at New Frontier.
____________________________________________ ______________________________
Client Acknowledgement Signature
SOCIAL MODEL DETOXIFICATION CLEARANCE FORM
___________________________________(Clients Name) is requesting admittance into New Frontier Treatment Center’s (NFTC) Social Model Detox program. This client must fall within the parameters listed below. Clients presenting with vitals exceeding these parameters should not be cleared for admission to NFTC and should be referred to a Medical Detoxification facility. Blood Pressure Systolic <170 or >90 ______ Pulse <100 or >60 _______
Diastolic <100 or >50 ______ Temperature <100.5 _______
Respiration <40 _______
Clients on the following medications or with the following diagnoses should be referred to a Modified or Medical Detoxification facility. If clients are admitted with the below diagnoses, consultation, documentation and continued involvement with client’s medical physician is required: Medications: Dilantin, multiple anti-psychotic medications, HIV/AIDS medications, Methadone/Buprenorphine, injection insulin/oral diabetic medications. History of seizures, HIV/AIDS, history of pancreatic conditions, unstable blood pressure, pregnancy, TB, paranoia/schizophrenia and chronic obstructive pulmonary disease. Authorized Detox Medications:
_____ Diazepam 10 mg orally, by mouth every 4 hours as needed for withdrawal symptoms for
2 days; then 4 times a day as needed for withdrawal symptoms. ____ Clonidine 0.1 mg orally, by mouth every 4 hours as needed for opiate withdrawal or blood pressure at or higher than 150/100. _____ Atenolol 25 mg orally, by mouth twice a day as needed for a pulse higher than 100. _____ Lorazepam (Ativan) 1-2 mg orally, by mouth 3 times a day for 3 days, then .5 mg. orally, by mouth 3 times a day for 3 days, then discontinue.
NFTC requests that clients take these medications only for the duration of the detoxification
process to prevent the possibility of addiction to these medications. Clients may take other
prescribed medications upon approval by NFTC Executive Director and Residential Program
Director upon consultation with client’s physician or emergency room physicians. Some of these
medications may include buprenorphine for opioid addiction, naltrexone as a medical treatment
for alcohol dependence, or other medications as directed by physician.
The clients must fill all Detox prescriptions and refrain from taking any of these
medications BEFORE their arrival at NFTC. They must have any other maintenance
medication they have been prescribed in a properly labeled prescription bottle.

The above client falls within the parameters and is cleared for admission to New Frontier
Treatment Center’s Social Model Detoxification unit.
__________________________________________ ________________________
Physician’s Name (Print and Signature)
__________________________________________ New Frontier Treatment Center 1490 Grimes Street, Fallon, Nevada 89406
(775) 423-1412 Fax (775) 423-4054

NAME: _________________________________________ TODAY’S DATE: _________________________________
AGE: _________ BIRTHDATE: _________________ DATE OF LAST PHYSICAL EXAMINATION: __________________
WHAT IS YOUR REASON FOR INITIAL VISIT?
SYMPTOMS: Check symptoms you currently have or have had in the past year.
GASTROINTESTINAL
EYE, EAR, NOSE & THROAT
Appetite Poor
Bleeding Gums
Breast Lump
Bloating
Blurred / Double Vision
Erection Difficulties
Depression
Bowel Changes
Crossed Eyes
Lump in Testicles
Dizziness
Constipation
Difficulty Swallowing
Penis Discharge
Fainting
Diarrhea
Glasses / Contacts
Sore on Penis
Excessive Hunger
Forgetfulness
Excessive Thirst
Ear Discharge
WOMEN Only
Headache
Hay Fever
Abnormal Pap Smear
Loss of Sleep
Hemorrhoids
Hoarseness
Bleeding Between Periods
Loss of Weight
Indigestion
Loss of Hearing
Breast Lump
Nervousness
Nosebleeds
Extreme Menstrual Pain
Numbness
Rectal Bleeding
Persistent Cough
Hot Flashes
Stomach Pain
Ringing in Ears
Nipple Discharge
MUSCLE / JOINT / BONE
Vomiting
Sinus Problems
Painful Intercourse
Pain, Weakness, Numbness in:
Vomiting Blood
Vision – Flashes
Vaginal Discharge
CARDIOVASCULAR
Vision – Halos
Tubal Legation
Chest Pain
Dentures
High Blood Pressure
Irregular Heartbeat
Bruise Easily
Last Menstrual Period?
Low Blood Pressure
Last Pap Smear?
Poor Circulation
Mammogram?
Rapid Heartbeat
Change in Moles
Are You Pregnant?
Shoulders
Swelling of Ankles
Number of Children?
Right Knee
Varicose Veins
Number of Pregnancies?
Left Knee
Sore that Won’t Heal
Blood in Urine
Frequent Urination
Lack of Bladder Control
Painful Urination
Difficult Urination

CONDITIONS: Check conditions you have had in the past.
Emphysema
Miscarriage
Typhoid Fever
Alcoholism
Epilepsy
Mononucleosis
Ulcers / Irritable Bowels
Glaucoma
Multiple Sclerosis
Vaginal Infections
Anorexia
Venereal Disease
Appendicitis
Gonorrhea
Pacemaker
Arthritis
Pneumonia
Heart Disease
Bleeding Disorders
Hepatitis
Prostate Problems
Breast Lump
Psychiatric Care
Bronchitis
Rheumatic Fever
High Cholesterol
Scarlet Fever
HIV Positive
Cataracts
Kidney Disease
Suicide Attempt
Chemical Dependency
Liver Disease
Thyroid Problems
Chicken Pox
Tonsillitis
Diabetes
Migraine Headaches
Tuberculosis
MEDICATIONS: List medication you are currently taking. (Include Over-the-counter drugs) ALLERGIES: To Drugs, Food, Substances etc.

Medications you should be taking and are not? Prescribed for? Last Taken?

HEALTH HISTORY – Page 2
(Confidential)
Relation
Age State
Cause of Death
Check if your blood relative has or had:
Diseases
Relationship
Arthritis, Gout
Asthma, Hay Fever
Brothers
Chemical Dependency
Diabetes
Heart Disease, Strokes
High Blood Pressure
Kidney Disease
Tuberculosis
Depression or Psychological Illness
HOSPITALIZATIONS
PREGNANCY
Hospital
Reason for Hospitalization and Outcome
Complications
Have you ever had a blood transfusion?
No HEALTH HABITS Check which substance you use,
If Yes, please give approximate date(s) how often, how much
Date
Serious Illness / Injuries
Caffeine
Gambling
OCCUPATIONAL CONCERNS
Check if your work exposes you to the following: Explain:
Occupation?
Hazardous Substances
Hours per Week?
Heavy Lifting
Education?
Personnel Conflict

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any
members of his / her staff responsible for any errors or omissions that I may have made in the completion
of this form.
________________________________________________________
____________________________
Signature

________________________________________________________
____________________________
Witness Signature
Letter of Explanation of Currently Prescribed Medications
New Frontier Treatment Center requires a doctor’s letter on all prescribed medications completed by the prescribing physician before entering treatment. Please list all prescribed medications with dosages, what condition the medication is being taken for: Medication Name Dosage Condition Treated 1. _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________________________ _______________ Physician Signature Date New Frontier Treatment Center
Requirement List
We will NOT go to the store at any time during treatment.
____________________________________________________________________ What TO Bring:
What NOT to Bring:
 Five to seven days of comfortable clothing  NO short shorts/skirts, tank tops/sleeveless clothing,
 Toiletry items such as shampoo, deodorant, shaving gear, midriff tops, baggy pants or gang apparel hygiene products, etc.(no alcohol based products) – please  NO clothing with inappropriate language, content or
bring your own as you are not allowed to share these items
 NO perfumes, colognes, aerosols, fingernail polish or
 Writing materials, envelopes, postage stamps and blue ink  NO books, magazines or non-recovery reading
 NO tobacco products
 NO cell phones, pagers, radios, walkman, disk-man,
 Laundry detergent and laundry bag/basket laptop computers, TV’s, CDs, cassette tapes, alarm  Housing fee according to the SAPTA sliding fee scale  NO jewelry allowed. (This includes tongue rings, or
 $75.00 for physical upon admit unless other arrangements  NO credit cards on the facility.
 $50.00-$200.00 for potential medical needs.  NO automobiles on the New Frontier property.
 Medicine in opened containers or containers w/o  NO Money is allowed on the unit
labels/improperly labeled or outdated will be sent home or destroyed  Medication-Doctor prescribed (30 day supply for each  Bring a phone card for outside phone calls. (New Frontier will not be held responsible for
 Bring current insurance card and Medicaid card if lost or stolen items.)
 Nicotine patches, lozenges, and gum if applicable.  Personal Water bottle for recreation Please Remember!!!
You must confirm your bed date with us and be on time for admission, failure to do so may result in losing your reservation. We would then reschedule your bed date at our convenience.  Absolutely no one will be admitted without a confirmed Intake appointment - unless other arrangements have  All pregnant women must have a medical release by a physician and an adequate supply of pre-natal  Head east on US 50 (Williams Ave.) turn right on Allen Rd. (at McDonalds), then left on Grimes St. to 1490. Transportation to and from New Frontier is your responsibility!!!
________________________________ ___________ _________________________________ __________ Client Signature CONTRABAND
Because we are a secure Center, and because we want to protect the safety of all the people at NFTC there are some things that are prohibited from being on the grounds of NFTC. These items will be confiscated and held secure as contraband or destroyed. Contraband items are defined: “Anything that can function as a weapon, instrument of self-harm or otherwise poses a threat of injury. Alcoholic beverages (beer, wine, whiskey), firearms handguns, shotguns, rifles, ammunition, and illegal drugs such as marijuana and cocaine. Aerosol containers Butane Lighters Glass or metal objects Knives or any item that could be used as a knife, such as ice pick, screwdriver, etc. Matches Dangerous items will be sent home. Confiscated contraband items are listed in the client file, secured and returned to the client upon discharge. Clients are encouraged to send valuables and cash home. Approved Medications
 The “Extra Strength” versions of the above medication is approved to take  Do not take any “Cold and Sinus” , “Allergy” or “Flu” versions of the above PRESCRIPTION NON-NARCOTIC PAIN MEDICATIONS: DO NOT TAKE ANY PAIN MEDICATONS WITHOUT PRIOR APPROVAL. This includes: Vicodin Percocet Darvocet Lortab Tylenol w/Codine Vicoprofen THIS INCLUDES MUSCLE RELAXANTS SUCH AS: Soma Robaxin For Allergies- Alka-Seltzer Plus Cold & Cough (Purple Box) Vicks 44m Cough & Chest Congestion (Purple Box) **Do NOT take any “Liquid Cap” version of the above medication **Sealed and unopened medication bottles/containers only
**You MUST take the correct amount of the above medication
**Only Regular vitamins may be taken
**DO NOT TAKE ANY HERBAL SUPPLEMENTS OR HERBAL DIET AIDS
SCREENING

Client Name: _________________________________________________________________
Date:______________________
Contact Code: ______In person
Interview Setting: Circle answer
Office / Home / Outpatient clinic / Outpatient hospital / Inpatient hospital /
Residential facility / Boarding home / Correctional facility / Mobile/Extended/Outreach /
Hospice / Nursing home / Other

Referred By: Circle answer
Alcohol Drug Abuse Care Program / Civil Protective Custody (CPC) / Court )Criminal Justice
Referral / Employee/EAP / Faith Based Organization / Individual (Includes Self Referral /
Other Healthcare Provider / School (Educational) / Unknown
PART ONE
During the last 6 months:
1.
Did you often use larger amounts of alcohol or drugs or use them for a longer time than Did you try to cut down on alcohol or drugs and were unable to do it? Yes / No Did you spend a lot of time getting alcohol or drugs, using them, or recovering from their Did you often get so high or sick from alcohol or drugs that it— Kept you from doing work, going to school, or caring for children? Yes / No Caused an accident or became a danger to you or others? Yes / No Did you often spend less time at work, school, or with friends so that you could drink or Did your use of alcohol or drugs often cause- - Emotional or psychological problems? Yes / No Problems with family, friends, work, or police? Yes / No Physical health or medical problems? Yes / No Did you increase the amount of alcohol or a drug you were taking so that you could get Did you ever keep drinking or taking a drug to avoid withdrawal or keep from getting Did you get sick or have withdrawal when you quit or missed drinking or taking a drug? Which drugs or alcohol caused you the MOST serious problems? See list below. Drug Name
# of days used in
the last 30 days
Primary Substance ___________________________ ____________________
Secondary Substance ___________________________ ____________________
Tertiary Substance ___________________________ ____________________
How often did you inject drugs with a needle? Circle answer Never / Only a few times / 1-3 times a month / 1-5 times a month / about every day How serious do you think your drug problems are? Not al all / Slightly / Moderately / Considerably / Extremely How many times before now have you ever been in an alcohol treatment program? How many times before now have you ever been in a drug treatment program? Do you think you need treatment for your drug use now? If “Yes,” answer question “a” below: How important to you is it that you get into some type of treatment program now? Not at all / Slightly / Moderately / Considerably / Extremely How many times have you received psychiatric or counseling services for reasons other Do you currently have a medical condition? If “YES” Choose no more than 3 conditions below: Circle answer Malnutrition Respiratory Lung Disease Injuries Other Medical Conditions?________________________________________________________ 18. What medications have been prescribed or have you been taking in the past 6 months for substance abuse or mental health problems? _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________
 GAMBLING BEHAVIORS
How old were you the first time you gambled (bet money or something of value on sports, a game of change or skill, played the lottery, or bet cards or dice games/? In the last 30 days, have you gambled for anything of value? If you have gambled in the past 12 months, how much money did you usually bet? In the past year, have you often found yourself thinking about gambling or planning to In the past year, have you ever spent more than you meant to on gambling? In the past year, has gambling lead you to lie to your family? Has the money you spent gambling led to financial problems? Has the time you spent gambling led to problems in your family, work, school, or Evaluation ___Yes ___No Outpatient ___Yes ___No NEW FRONTIER TREATMENT CENTER CLIENT INFORMATION DIAGNOSIS CODE ________________________________ CLIENT # __________________________ DATE ________________________ REFERRAL SOURCE ______________________________________________________________________________________________ CLIENT NAME _______________________________________________________ DATE OF BIRTH _______________________________ HAVE YOU PREVIOUSLY BEEN ADMITTED TO NEW FRONTIER ______No ______Yes ________________________________Year DO YOU HAVE A BALANCE ON YOUR ACCOUNT? ______________________ AMOUNT? ______________________________________ EXPLANATION ____________________________________________________________________________________________________ GENDER: __MALE, __FEMALE. MARITAL STATUS: __MARRIED, __DIVORCED, __SINGLE, __WIDOWED: SS# ________________ RESPONSIBLE PARTY (IF A MINOR) __________________________________________SS# (of R. party)__________________________ MAILING ADDRESS: _____________________________________________ CITY __________________________ ST ____ ZIP _______ PHYSICAL ADDRESS: ____________________________________________CITY____________________________ST_____ZIP________ HOME PHONE: _______________________________ WORK PHONE: ________________________________ ________ NO ________ YES _______________ HOURS PER WEEK ________ NO ________ YES _______________ HOURS PER WEEK EMPLOYER NAME: ____________________________ EMPLOYER PHONE _________________________________________ EMERGENCY CONTACT _______________________________/_____________________ PHONE ________________________________ Relationship NEAREST RELATIVE NOT LIVING WITH YOU _________________/__________________ PHONE ________________________________ Relationship
DO YOU HAVE TANF (STATE ASSISTANCE) OR OTHER SOURCE OF COVERAGE? _________ NO __________ YES
DO YOU HAVE INSURANCE? __________ NO __________ YES ATTACH A COPY (FRONT & BACK) OF INSURANCE CARD

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE
I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits or
any other benefits to myself or to the party who accepts my assignment below.
_____________________________________ _________
_____________________________________ _________ PAYMENT RECEIVED: ___________________________
FOR OFFICE USE ONLY
PAYMENT AGREEMENT
(Residential) MONTHLY PAYMENT OF $_______________ BEGINNING _______________________. (Outpatient) PAYMENT OF $______ PER INDIVIDUAL SESSION AND $______PER GROUP SESSION, DUE AT THE TIME OF SESSION. I, _________________________________________, fully accept the responsibility for the cost of the services being provided by New Frontier and hereby agree to this responsibility as described above. I further understand that this cost will not be a deciding factor for admission to the program and that payment will be arranged in a manner compatible with my income. I agree that in the event my insurance does not cover treatment costs, I accept responsibility for the cost at the above sliding fee scale rate. I agree that if I do not complete the program, I am responsible for the cost of the treatment and all additional charges incurred. I further understand that it is my responsibility to make payments on a regularly monthly basis or per session or I will contact Accounts Receivable at (775)423-1412 or (800)232-6382 to make arrangements, otherwise the account may be forwarded to an outside collection agency. I also understand and agree to pay any charges for drug testing incurred (pre-admission/random testing.) I agree that if I miss a scheduled session without calling to cancel, I will be responsible at the sliding fee scale rate. IF MY INSURANCE IS BILLED AND FOR ANY REASON DENIES PAYMENT, I REALIZE I AM FULLY RESPOSIBLE FOR PAYMENT. ______________________________________________________________ ______________________________________________________________

Source: http://www.spotnot.net/application.pdf