Larc Program Hospital Jamaica Form – Fill Out and Use This PDF

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

The !!"# (LARC) is an intensive residential program which offers comprehensive substance abuse stabilization and case management/housing search services for up to 90 days. Such services are provided within a treatment'planning model that is individualized to meet the unique needs of each client. In this way, LARC offers a safe and structured space in which program participants can focus on establishing or re' establishing rituals of recovery and wellness that enhance quality of life.

LARC serves men and women living with HIV/AIDS and alcoholism and/or drug addiction whose histories of addiction relapse have jeopardized their ability to access and/or maintain stable residency in either treatment or housing programs. LARC fully integrates persons involved in methadone treatment into the stabilization program.

Individual Addiction/Relapse Prevention Counseling

Group Counseling (over 30 groups weekly)

Comprehensive Case Management

Housing Search Counseling and Advocacy

Stress Reduction Trainings

Life Skills Building, Medication Management and Stress Reduction Techniques

18 years of age or older

History of alcoholism and/or drug addiction with recent instability/relapse

HIV infection

Medical clearance for inpatient substance abuse treatment (detoxification from all illegal and/or unprescribed substances)

Medical, psychiatric and neurologic stability with the ability to engage in the program

Non'infectious tuberculosis status

LARC is located on the 11th floor (north) of the Lemuel Shattuck Hospital in Jamaica Plain. The hospital building itself is situated on the edge of Franklin Park within walking distance of the Forest Hills Orange Line T Station.

The LARC program has 20 comfortable private and semi'private beds, 4 spacious bathrooms, an ample kitchen and dining area, a large solarium/group room, and several staff office spaces. In addition, LARC has laundry facilities which include clothes washers and dryers. The LARC program is handicapped accessible.

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

$$

To be eligible for admission, an applicant !"%#& documentation of the following:

1.A history of alcoholism and/or drug addiction

2.Medically, Psychiatrically and Neurologically able to participate in an intense treatment program

3.HIV infection, including CD4 count and Viral Load Number (within last 4 months)

4.Medical clearance for inpatient treatment (detoxed from all illegal and unprescribed substances)

5.Recent instability in her/his addiction recovery (relapse or risk of relapse)

6.Verification of Financial Resources and Expenses

In order for the application to proceed, all release formsneed to be signed allowing the clinical staff of Victory Programs Living and Recovering Community (LARC) to communicate with their primary care physician, mental health provider(s), methadone provider, and any other relevant care providers.

$

Phone Screening

An initial phone screen is conducted to insure that the applicant meets the eligibility criteria.

Document Completion

The identified provider coordinates the completion and return of required forms and the submission of appropriate documentation, including:

Program Application Form.

Physician’s Referral Form.

Applicant’s Consent to the Release of Information Form(s)

Financial Resources and Expenses Verification Documentation

Methadone Provider’s Referral Form (if applicable)

Face to Face Interview

The applicant comes to LARC for an interview with program staff. This interview includes:

The initial intake assessment

Signing of necessary releases to continue the intake process

Signing of the Client Agreement to Program Participation and the Client Agreement to Rights and Responsibilities

Program Acceptance

>111?*"@.?15

6

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

'#(%%###)'%**!#

I, ________________________________________, authorize the staff of the

referring program __________________________________________________,

and the staff of The Living And Recovering Community (LARC) to exchange any

information regarding my addiction, health care, and case management needs and

resources that may be useful in facilitating my application and possible admission to

the LARC program. I understand that my records are protected under the federal

regulation governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42

CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996

(“HIPPA”), 45 C.F.R. Pts. 160 & 164, 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 the event this consent expires one year from its

execution or upon the withdrawal of my application or my discharge from the LARC

program.

_____________________________	________________________
Signature of Client	Date
_____________________________	________________________
Signature of Witness	Date

7

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

*(%!

$

Applicant’s name: _____________________________________________________

Current address:_______________________________________________________

Telephone #: _________________________________________________________

Age: ________ Date of birth: _________ Gender: _________ Pregnant (Y/N) _____

SS#: ________________________________ Language(s) spoken: ______________

Has the applicant participated in the LARC program before? ________ When? _____

$

Name of referring provider: _____________________________________________

Relationship to applicant: _______________________________________________

Agency: _____________________________________________________________

Address:_____________________________________________________________

Phone: ___________________________________ Fax:_______________________

Provider’s signature and date:____________________________________________

Reasons for LARC Referral: _____________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

+

Description of applicant’s most recent addiction relapse: ______________________

____________________________________________________________________

Description of applicant’s current recovery status:____________________________

____________________________________________________________________

Description of current alcohol/ drug usage (if applicable): ______________________

____________________________________________________________________

Description of applicant’s detoxification needs: ______________________________

Is the applicant involved in methadone treatment? Yes___ No: ___ Dosage: ______

Methadone provider agency name and #: ___________________________________

=

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

$$

Name of primary care physician: _________________________________________

Physician’s phone number: ______________________________________________

Other involved health care agencies (CMA, VNA,I)?: _______________________

Date of HIV diagnosis: _________________________________________________

Opportunistic infections and dates: ________________________________________

____________________________________________________________________

Does applicant have any neurological involvement related to HIV? Please describe:

____________________________________________________________________

____________________________________________________________________

Current medications: __________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Current medical status: _________________________________________________

____________________________________________________________________

$

What is the applicant current housing situation?______________________________

____________________________________________________________________

Is applicant’s current housing situation safe? ________________________________

____________________________________________________________________

What are the applicant’s housing needs? ___________________________________

____________________________________________________________________

Amount of monthly rental payment (if applicable): ___________________________

$$

Is applicant currently seeing mental health care provider? Yes____ No____

How frequently? ________________________ Date of last visit:________________

Mental health care provider’s name: _______________________________________

Mental health provider’s phone #:_________________________________________

%

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

Psychiatric history (include diagnosis and type of treatment):

__________________________________________________________________________

__________________________________________________________________________

$$$

What are the applicant’s immediate case management needs?

__________________________________________________________________________

__________________________________________________________________________

What workers/ agencies are providing case management support to the applicant at present?

__________________________________________________________________________

__________________________________________________________________________

Does the applicant have legal cases pending, and if so, what is the current status of these legal issues?

__________________________________________________________________________

__________________________________________________________________________

$

Applicant’s total current monthly household income: _______________________________

Current sources of income (include employment, benefits, food stamps, other sources):

__________________________________________________________________________

Medicaid number and type: ___________________________________________________

Recipient identification number (if applicable): ____________________________________

Other Insurance (CMA, NHP, HCHP)? __________________________________________

Married: ____ Unmarried: _____ Divorced: _____ Widowed: _____ Couple: _____

Name of significant other (if applicable): _________________________________________

Does applicant have children, and if so, how many?________________________________

Describe applicant’s “family” and/or system of support: _____________________________

__________________________________________________________________________

Describe presence of addiction in applicant’s family? ______________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

9

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

		#$"#!%$"#
		# $&" ' %($ )
		%$*#*"'#*
		! $& "$"#
		$)!*

,"%#*) %(%#*#*-##"%

___________________________	_______________________________
Name of Client	Client’s Date of Birth
___________________________	_______________________________
Name of Primary Care Physician	Physician’s Phone Number

!"

I, ____________________________, authorize my physician,________________________,

to disclose to LARC the information requested on this form to assist in my admission to and participation in the LARC program. 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 one year from its executions or upon the withdrawal of my application or my discharge from the LARC program.

______________________________	________________________________
Signature Client	Signature of Witness

+(

I, __________________________________________ (please print name), am currently

providing medical care for ______________________________________________ at the

following clinic/hospital, __________________________________________. As such, I

certify that he/she;

a diagnosis of AIDS

is HIV symptomatic

is HIV asymptomatic

$

The following blood counts, indicated below, have been taken within the last four months;

	."#		'		#*/0

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA		AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
		!
			3

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

		#$"#!%$"#
		# $&" ' %($ )
		%$*#*"'#*
		! $& "$"#
		$)!*

$$$$

The applicant, ___________________________________, is currently on the following

medication regimen. Please complete the below list accurately or attach a copy of the applicant’s current medication list. For this application to be processed further, an applicant

must have a 12 %"&&' *!# should he/she be admitted to the program.

"#$%#!&

	Medication Name	Dosage	Frequency
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
'&
	Medication Name	Dosage	Frequency
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA
	AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAA	AAAAAAAAAAAAAAAAAAAA

Tuberculosis Assessment is attached to this application

Additional TB information is attached to this application

B

Client Name:

Today’s Date:

#$"#!%$"# # $&" ' %($ ) %$*#*"'#* ! $& "$"# $)!*

$$

_______________________________

_______________________________

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

The following over'the counter medications are permissible to use as indicated per manufacturer’s recommendations on a PRN basis only and will not conflict with the client’s current medication regimen. The medication doses are not to exceed the manufacturer’s daily recommended dosages:

Acetaminophen

Ibuprofen

Naproxen

Aspirin

Tums/Rolaids

Other: ____________________________

Provider’s Name: __________________________________________

Provider’s Phone: __________________________________________

Provider’s Signature: __________________________________________

;

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

		#$ ! %$&*#
		"#$ "#!%$"#
		# $&" ' %($ )
		%$* #* "'#*
		! $& "$"# $
		)!*
	$#)(%*'!
	___________________________________	__________________________
	Name of Client	Client’s Date of Birth
	___________________________________	__________________________
	Methadone Provider Agency	Staff Contact
	___________________________________	___________________________
	Mailing Address	City, State and Zip Code
	___________________________________	___________________________
	Date of Client’s Entry into Methadone Program	Telephone Number

'#(%%###)'%**!#

I, ________________________________________________________, authorize the above

agency, _____________________________________________, to disclose to LARC the

information requested on this form to assist in my admission to and participation in the LARC program. I understand that my records are protected under the Federal Regulations governing Confidentiality of Alcohol and Drug Abuse 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 it has been taken in reliance on it, and that in any event this consent expires one years from it’s execution or upon withdrawal of my application or my discharge from the LARC program.

_______________________________________	_____________________________
Signature of Client	Date

$#)(%*!#

Briefly describe the applicant’s dosage history: ______________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Briefly describe the client’s methadone treatment goal (i.e., detox or maintenance)

_____________________________________________________________________________

_____________________________________________________________________________

Documentation of most recent six urine toxicology screens:

Date	Results
_______________	______________________________________________
_______________	______________________________________________
_______________	______________________________________________
_______________	______________________________________________
_______________	______________________________________________
_______________	______________________________________________
Methadone Provider Staff Signature_________________________________________

&

$#)*#!#

#$ ! %$&*# "#$ "#!%$"# # $&" ' %($ ) %$* #* "'#* ! $& "$"# $ )!*

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

Client Name: _________________________________ Date of Birth: _______________

Home Methadone Clinic: ___________________________________________________

Home Methadone Clinic Fax Number++++++++++++++++++++++++++++++++++++++++

Home Methadone Contact Person: ___________________________________________

Home Clinic Phone Number: ________________________________________________

This is an agreement between the Living and Recovering Community (LARC) of Victory Programs, the client listed above, and his or her home methadone clinic listed above. While at LARC, the client is courtesy dosed at the Methadone Assessment and Treatment (MAT) of Roxbury Comprehensive Community Health Center, located at the Lemuel Shattuck Hospital in Jamaica Plain, the same building in which LARC is located. Upon discharge from LARC the MAT Program ceases courtesy dosing for the LARC client, and the client must return to his or her home clinic for continued dosing.

This is an agreement that, _________________________________________________,

(client name)

will resume services at his or her home clinic, _________________________________,

(home clinic name)

after discharge from the LARC Program. The home clinic will be notified when the client is discharged from LARC by staff of the LARC program and/or the MAT Program. Further arrangements to coordinate care can be made by contacting LARC.

Client Signature: ____________________________________________ Date: ________

Home Clinic Staff Signature: __________________________________ Date: ________

LARC Staff Signature: _______________________________________ Date: ________

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

Clients who are admitted to LARC should bring the following items:

Casual day time clothes, pajamas and a robe

It is suggested that valuables not be brought into the program

Toiletry items, shampoo, toothpaste, etc.

Towels, washrags, etc.

Small alarm clock

Comfortable shoes

Comforter and your own pillow

Insurance card/picture ID

Money to purchase small items

Small radios (televisions are not permitted)

Cell Phone (policies will be explained during intake)

Laundry facilities are available on the floor, but you need to bring your own laundry detergent as each new admission is required to wash his or her clothing upon admission.

As this is a coed program, clients are not expected to wear clothing that is sexually provocative or explicit. All shorts must be of appropriate length and undergarments must be worn at all times. Pajamas are not permitted to be worn to groups, on the floor after morning wake up routine or outside during fresh air breaks. Any clothing with references to drugs, alcohol, tobacco or gambling are not permitted. Shirts and shoes should be worn at all times for sanitary reasons.

6

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

7

!"!#$%&'

()

*"

+*",

-./

!

"/

"/0

"

1

/

/

/

)1

)1

*"!

*21 3&45-

(!4&67&

8935%66:6;79

<8935%66:7=%

8...515

Updated 11.2011

FINAL3CHECKLIST FOR PROVIDERS/REFERRAL SOURCES

()((&

Please fax this packet back to 617'522'1345 Attn: Don Drake, PD

4567899751.8 Attn: Don Drake

Please be sure that all paperwork is fully completed, especially the following itemsPlea easbetheysuremayth t allcausepaperworkdelayis infullythecompleted,intake process:especially the following items as they may delay the intake process:

[ ] The HIV Certification is completed by the applicant’s medical provider along with the most recent CD4 count and Viral Load Count

[ ] The HIV certification is completed along with the

current CD4

[ ] The applicant/client is discharged with 30 days of medication. If you and Viral Load counts and signed by the physician

would like to call in the medication, LARC uses the following pharmacy:

[ ] The client is discharged with 30 days worth on medication. If you would like

$+:82;768.7;;6;*&%/% to call that medication in, the pharmacy that LARC uses is:

Note:)!On Friday admissions,7508'754'8878medicationsfor prescribersmay not be delivered until late Monday afternoon so please take this into account when planning weekend medication coverage Note:for theAdmissionsclient. on

Friday may not have their medication

[ ] Is the over the counter medicationdeliveredpermission sheet reviewed and until Monday. Please

completed by the client’s prescriber. Not completing this may limit the take this into consideration when

client’s ability to use over the counter medications. planning

medication coverage for

[ ] If the client is using methadone assisted treatment, are al forms the client.

completed per instructions?

[] Clients at LARC participate in the Community Servings Meal Program.

] Is the over the counter medication sheet reviewed and signed by the

Pleasem dicalbeprovidsurer?that &51, the Home Delivered Meals Program sheet for Community Servings is completed and signed / #)!' &<=%#=)%#"%<

[ ] If the client is using methadone assisted treatment, are all the forms completed per instructions?

[ ] Client is aware of what items he/she are required to bring to the program. Please notify the program ahead of time if the client does not

have access to some of the items.

[ ] Clients at LARC participate in the Community Servings Meal Program.

Please be sure that &51, the Home Delivered Meals Program for

[ ] Cell phones are permitted but can be used in the privacy of the room Community Servings, is completed and signed by the medical providers. only.

LARC staff will complete the Community Servings Packet and fax over lab results and medication list.

If you need anything or have any questions, please do not hesitate to contact us at 617'522'2936. Thank you.

[ ] Client is aware of what items he/she are to bring to the program.

=