Admission Application Form

WARM SPRINGS ADDICTION TREATMENT AND CHANGE PROGRAM
P. O. BOX G
WARM SPRINGS, MT 59756
Phone: 406.693.2272 or Fax: 406.693.2276

Admission Application Form

This form is to be completed by those persons who wish to enter and participate in the Warm Springs Addiction Treatment and Change Program. Please complete all questions and return the completed application to the above address, ATTN: Program Administrator. Your referent will be notified within ten working days, after receipt of the completed form, of your admissions status (acceptance or denial) to the treatment program. Incomplete, missing or false/misleading information on this application will be cause for rejection of admission.

Are you aware that the Warm Springs Addiction Treatment and Change Program is a highly intense, 6-month Modified Therapeutic Community, that incorporates chemical dependency counseling with behavioral restructuring and other correctional programming thus requiring a great deal of participation and commitment? (Yes or No)_______

Having the understanding of the demanding structure of Warm Springs Addictions Treatment and Change Program, and the knowledge that should you be removed from the WATCh Program, that the MDOC has the authority to place you elsewhere, are you willing to make a commitment to participate fully in the WATCh Program? (Yes or No)_______.

If your answer to this question is Yes, please continue with the application.

Name:__________________________________ AO#: _____________________

Date of Birth:___________ Marital Status:____________ SSN:_______________

Name of person referring you to WATCh:_________________________________

Referent’s phone number:_____________________________________________

Current Legal Charges (On your Court Judgment(s): _______________________

Length of Sentence:_________________________ Date of Sentence:_________

Number of previous Felony charges (Not including current charges):__________

Please Detail Felony charges:___________________________________________

____________________________________________________________________

Date of last alcohol and/or drug use: ______________ Amount used?_________

What did you drink or use:_____________________________________________

What are your drugs of choice?1. _____________ 2. ____________ 3. __________

Any IV use?________________________ If yes, what?_____________________

Do you have a history of problem gambling? (Yes or No) ______________. If yes, do you
think it is your primary problem, or do you only gamble due to chemical usage? Please
elaborate. ______________________________________________________________________________

______________________________________________________________________________

Have you ever been treated for a gambling addiction? ___________ If yes, do you
think that your gambling problem is as severe as your chemical usage?__________ Have you or do you attend GA?___________.

Please list the previous OUTPATIENT treatments you have experienced for drugs and/or alcohol and if you completed:

Treatment Provider Completed (Y or N) Date of Completion

____________________________________________________________________________

_____________________________________________________________________________

Please list the previous INPATIENT treatments have you had?_______________________

____________________________________________________________________________

Treatment Provider Completed (Y or N) Date of Completion
____________________________________________________________________________

____________________________________________________________________________

__________________________________________________________________________

How long after your last treatment did you stay clean/sober?________________________

What is the longest time you have gone without mood altering chemicals? ____________

___________________________________________________________________________

How did you accomplish that?________________________________________________

__________________________________________________________________________

What do you see is the cause of your inability to stay clean/sober?__________________

___________________________________________________________________________

Do you have past AA or NA experience?_______________________ If yes, for how long did you attend meetings?____________________ Did you work the steps?______________
Did/Do you have a sponsor?_____________________

Do you have a past/current Mental Health history?________________ If yes, with whom
did/do you receive counseling?_______________________________________________

__________________________________________________________________________

For what conditions?________________________________________________________

__________________________________________________________________________

Have you been diagnosed with this condition?___________________________________

Are you currently taking any prescribed medication for the Mental Health condition?___

If yes, please list the name(s) and dosage(s), and frequency(s)_______________________

___________________________________________________________________________

Name, address, and phone number of Physician or Psychiatrist who made the diagnosis: ___________________________________________________________________________

Are you currently suffering from any Eating Disorder?______________________________

If yes, what is the disorder, and do you think it could interfere with your treatment stay at WATCh?______________________________________________________________________________

Do you have any physical impairments that would interfere with your ability to actively and fully participate in all components of the WATCh Program?________________________________

If yes, please indicate what they are:_______________________________________________

______________________________________________________________________________

Are you currently being treated for any Medical Conditions? (Yes or No)_________________

If yes, please indicate what they are and how often you see your physician: _____________________________________________________________________________

_____________________________________________________________________________

Please list any medications you are currently taking for a Medical Condition:

Medication Amount Dosage Frequency
________________________________________________________________________________

________________________________________________________________________________

What was your address prior to this Offense? _________________________________________

Will you be returning to this address? (Yes or No)______________________________________

What was your occupation and employer prior to the current offense?__________________
_____________________________________________________________________________

Will your employer hold your position until your release? (Yes or No) ___________________

Are you receiving SSI, Disability, or some other type of assistance?_____________________

If yes, what are you receiving and why: __________________________________________
________________________________________________________________________

WATCh may have a waiting list for admission and the time frame for availability of an admission date does vary. The admissions staff at WATCh understands that many applicants will remain incarcerated until his/her admission date arrives. We do our best to get you admitted as soon as possible. Thank you for your interest in the WATCh Program.

By signing this application for admission, I do believe I have answered all of the questions and provided the information honestly to the best of my ability.

WAIVER

I have been informed of the WATCh Program and I understand that I am being considered for placement. I have read, understand, and accept the terms and conditions listed below.

__________________________________________ __________________
Signature of Applicant Date

_____________________________________________
Phone number where you can be reached.

___________________________________________________________________________
Address

The following section is Consent for Release of Confidential Information.

Please just sign and date the bottom, as well as have a witness sign and date the bottom. Please leave the rest of the form blank!

Consent for the Release of Confidential Information

Warm Springs Addictions Treatment and Change Program
P. O. Box G
Warm Springs, MT 59756

I, ___________________________________________, authorize the exchange of information
between the Warm Springs Addictions Treatment and Change Program and the following treatment
provider:

________________________________ ____________________________________
Name of Provider Address

__________________________________ ____________________________________
Telephone Number Fax Number

The following information listed below may be furnished or obtained either in writing or via telephone or fax by the Intake/Screening Committee of WATCh Program.

______________Presence in Treatment

______________ CD Evaluation results and recommendations

______________ Presence in Aftercare

______________ Discharge Summary

______________ Mental Health/Psychological Evaluation and Diagnosis

I understand that my records are protected under the Federal Confidentiality Regulations (42 CFR Part 2) and cannot be disclosed without my written permission unless otherwise provided for in the regulation. 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 in the event this consent expires automatically 180 days from the date listed below.

This release of confidential information expires 180 days from the date listed below.

____________________________________________ _________________________
Signature of Applicant Date

_____________________________________________ _________________________
Witness Signature Date

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