The Children s Addiction Prevention Program at Brighton Center for Recovery

Transcription

1 The Children s Addiction Prevention Program at Brighton Center for Recovery Dear Parents: Thank you for your interest in the Children s Program at Brighton Center for Recovery and for giving your child (ren) this wonderful opportunity! Please fill out the enclosed paperwork and return to: Brighton Center for Recovery, Children s Program, attn: Pat Schafer, Grand River, Brighton MI Please include a $50.00 check (per family) security deposit made payable to Brighton Center for Recovery to secure your place in the program. Your deposit will be returned to you when you attend the program. However, your deposit will be forfeited if you reserved a space for the program, but do not follow through. Sorry, no exceptions will be made. Important Information: This 3- day program is offered once a month from Friday thru Sunday, 9:00am-3:00pm at the Annex building on the campus of Brighton Center for Recovery. The Annex building is a separate building, just right of the main entrance to rehab and the gift shop and is marked as building #5. Children will participate all 3 days, and parents will participate all day on Sunday. Parents will also attend an hour orientation from 9am 10am on the first day, Friday. Please arrive 10 minutes early each day of the program so we can get started right at 9:00am. Snacks, beverages and lunch will be served Friday and Sunday. Please inform the staff of any food allergies ahead of time. If children need to take any medications or inhalers, etc. during the program, please give the medication to the staff with clear directions on how and when your child should take it. If you have any questions before or during the program, please contact Pat Schafer, LMSW, CAADC at: We look forward to meeting your family! Page 1 of 6

2 Children s Program Registration Form Today s Date: Program Date: Name of Person Completing this Form: Relationship to Child: Children Participant Information (Please list each child): 1. Child s Name: Age: Date of Birth: Gender: Female/Male Is child aware of addiction? Yes/No Is child seeing a therapist? Yes/No Child s 1st time attending this program? Yes/No Does the child have stomachaches, headaches, sleeping problems, or eating problems? Yes/No If yes, please describe: Describe any problems your child is having in school: Describe any problems y ou child is having at home: Describe any history of abuse or neglect (physical, sexual, verbal): Describe any major life changes within the past year for your child: (Death, separation, moves, etc) Has your child ever been diagnosed with? Anxiety Depression ADD/ADHD Other: Is your child currently on any medications? If so, what medication? 2. Child s Name: Age: Date of Birth: Gender: Female/Male Is child aware of addiction? Yes/No Is child seeing a therapist? Yes/No Child s 1st time attending this program? Yes/No Does the child have stomachaches, headaches, sleeping problems, or eating problems? Yes/No If yes, please describe: Describe any problems your child is having in school: Describe any problems your child is having at home: Describe any history of abuse or neglect (physical, sexual, verbal): Describe any life changes within the past year for your child: (Death, separation, moves, etc) Has your child ever been diagnosed with? Anxiety Depression ADD/ADHD Other: Is your child currently on any medications? If so, what medication? 3. Child s Name: Age: Date of Birth: Gender: Female/Male Is child aware of addiction? Yes/No Is child seeing a therapist? Yes/No Child s 1st time attending this program? Yes/No Does the child have stomachaches, headaches, sleeping problems, or eating problems? Yes/No If yes, please describe: Describe any problems your child is having in school: Describe any problems y ou child is having at home: Describe any history of abuse or neglect (physical, sexual, verbal): Describe any life changes within the past year for your child: (Death, separation, moves, etc) Has your child ever been diagnosed with? Anxiety Depression ADD/ADHD Other: Is your child currently on any medications? If so, what medication? Page 2 of 6

3 Parent Information/Legal Guardian Information: Parent/Guardian: Single Married Separated Divorced Widowed Widowed-Remarried How frequent is visitation with other parent/guardian(s)? If Divorced/Separated, does child(ren) see other parent? Yes/No Please Explain: CPS Referral? Yes/No If Yes, please explain: Mother s Name: Address: City: State: Zip Code: County: Home Phone #: ( ) Cell Phone #:( ) Work Phone #:( ) address: In Recovery? Yes/No If yes, how long in recovery? Former Patient at Brighton Center for Recovery? Yes/No Currently in Treatment at Brighton Center for Recovery? Yes/No Elsewhere? Yes/No Father s Name: Check if Father s address same as mother Address: City: State: Zip Code: County: Home Phone #: ( ) Cell Phone #:( ) Work Phone #:( ) address: In Recovery? Yes/No If yes, how long in recovery? Former Patient at Brighton Center for Recovery? Yes/No Currently in Treatment at Brighton Center for Recovery? Yes/No Elsewhere? Yes/No Page 3 of 6

4 Other Caregiver/Guardian Name: Caregiver Relationship to Child? Address: City State County Home Phone #: ( ) Cell Phone #:( ) Work Phone #:( ) address: In Recovery? Yes/No If yes, how long in recovery? Former Patient at Brighton Center for Recovery? Yes/No Currently in Treatment at Brighton Center for Recovery? Yes/No Elsewhere? Yes/No Family History: Are there any other family member(s) who have/had a problem? 1. How long was addiction? Months/Years In Recovery? Yes/No If Yes, How Long? Months/Years 2. How long was addiction? Months/Years In Recovery? Yes/No If Yes, How Long? Months/Years Additional Information: Please describe any concerns you may have about your child(ren)? How do you hope the Children s Program will benefit your child(ren) and you? Page 4 of 6

5 Other information you would like the Children s Program staff to know to better assist your child(ren): Location you and your child(ren) will be staying during the program: Person s name who filled out this form: Relationship to Child: Who referred your family to the Children s Program? Name of Referent: Address: City/State: Zip Code: Referent Phone #: Participation in Children s Program on Sunday (check all that apply) Mother Father Grandparent Guardian Other Page 5 of 6

6 Brighton Center for Recovery Children s Addiction Prevention Program Consent to Participate I consent to allow my child to participate in The Children s Addiction Prevention Program at Brighton Center for Recovery: Name of Minor Birth Date Print Name of Parent(s) or Guardian(s) Signatures Parent(s) or Guardian(s) Name of Emergency Contact Person (Relationship to Minor) Emergency Contact Phone # I am aware that participation in the Children s Program at Brighton Center for Recovery involves certain activities (such as, physical play activities) which are physically demanding and potentially dangerous for children. Therefore, as a participant, my child must be free of medical or physical conditions which might create undue risk. I understand that physical strength is not necessary, although being in good physical condition will increase enjoyment of the activities. I am aware that these activities involve a potential risk for illness and injury to my child and property. I acknowledge that I am aware of and assume all risks and wish to allow my child to participate in the activities. As part of the consideration for my child s participation in the Children s Program, I agree to assume full responsibility for any loss, injury, or inconvenience that my child might suffer. To the extent that I participate in such activities, I further agree to indemnify and hold harmless Brighton Center for Recovery and all its subsidiaries and officers from any and all liability incurred as a result of participation by myself or my child. I also agree that the terms hereof shall serve as a release and assumption of risk for my heirs, executors and administrators, and for all members of my family. I am aware and accept my responsibility to comply with any custodial arrangements that might exist with another parent or legal guardian who has the legal right to make decisions in our child s life. Medical Information: It is necessary for us to know if your child has any medical considerations. If not, please write no ; if so, please write yes. Please describe in detail and send any medications with your child to Brighton Center for Recovery. You may write long answers on the back of the form. Please initial and date information on the back. Chronic Medical Condition (i.e., diabetes, asthma, seizures, etc.) Allergic Reactions (i.e., to insect bites, stings, or poison oak? to any medications?) Any Surgery, Sprained Muscles, or Broken Bones within the Past 12 Months? Yes or No (circle one) Authorization to treat a minor: In the event I cannot be reached in an emergency, I hereby give permission to the person named as emergency contact to authorize medical and hospital care of my child and if such person cannot be reached, I give permission to the physician on-call at Providence Park Hospital to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child as named above. By signing this form I acknowledge that I have had the opportunity to read this form (or have it read to me), ask questions and have these questions answered. I understand and agree to the statements on this form. Signature (Parent/Legal Guardian must sign for persons under 18) Date Page 6 of 6