CHOICES IN LIVING COUNSELING CENTERS, INC .
PAGE 1
LEVEL II ALCOHOL EDUCATION PROGRAM ENROLLMENT
APPLICATION FOR ADMISSION
(*Page 1 and 2 are designed to fast-track your enrollment; additional State and Dept. of Health forms will be required)
Full Name:
Address:
DOB:
INTAKE DATE:
Tuesday, July 19, 2011
YOUR CELL PHONE:
(
) _____ - _______
YOUR WORK PHONE:
(
) _____ - _______
YOUR DRIVER’S LICENSE No. ST: ____ # __________
YOUR PRESENT AGE:
YOUR GENDER:
YOUR ETHNICITY:
PLACE OF BIRTH (city/state):
EMERGENCY CONTACT INFORMATION:
NEAREST RELATIVE (not living w/ you):
THEIR ADDRESS:
NOTIFY:
CURRENT RELATIONSHIP STATUS:
SPOUSE NAME:
SPOUSE OCCUPATION:
SPOUSE AGE:
No. OF MARRIAGES (include common-law):
LIST ALL BIOLOGICAL CHILDREN BY:
Child’s Age
Child’s Gender
Child’s Other Bio-Parent
1.
2.
3.
4.
5.
Total No. of persons who live at your address:
Who do you live w/? (ex. parent(s) ,roommates, etc.):
SSN:
CURRENT COURT ORDER: YES___OR NO__
CURRENT CASE PENDING: YES___OR NO___
COUNTY/CITY OF CASE:
TYPE OF CASE (ex: DUI):
PROBATION OFFICER:
PROBATION OFFICER PHONE:
NEXT COURT DATE:
COURT CASE No.:
PHONE:
PHONE:
Relationship to you:
ARREST HISTORY
Year and Location
Charge(s):
1.
2.
3.
4.
5.
Alcohol ConsumptionQuantity(how much):
Frequency(how often):
Age of 1st Alc-drink:
Last time drank-Alc:
Last 12 mos.
PRIOR ALCOHOL OR DRUG TREATMENT – location & dates (Include detox – rehab – inpatient - hospitalization)
1.
2.
3.
CHOICES IN LIVING COUNSELING CENTERS, INC .
Page 2
*US Dept. of Health & Human Services . .www.hhs.gov/ocr/privacy/hippa/understanding/summary/index.html
Notice of Privacy Practices – HIPPA 1996
Federal Law, specifically the Health Insurance Portability and Accountability Act (HIPPA) of 1996
requires that you be informed about Choices in Living Counseling Centers’ PRIVACY PRACTICES and
that you acknowledge receipt of said practices. The US Office for Civil Rights enforces the HIPAA
Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA
Security Rule, which sets national standards for the security of electronic protected health information;
and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being
used to analyze patient safety events and improve patient safety.
General Principle for Uses and Disclosures: Basic Principle. A major purpose of the Privacy Rule
is to define and limit the circumstances in which an individual’s protected heath information may be used
or disclosed by covered entities. A covered entity may not use or disclose protected health information,
except either: (1) as the Privacy Rule permits or requires; or (2) as the individual who is the subject of the
information (or the individual’s personal representative) authorizes in writing. Required Disclosures. A
covered entity must disclose protected health information in only two situations: (a) to individuals (or
their personal representatives) specifically when they request access to, or an accounting of disclosures of,
their protected health information; and (b) to HHS when it is undertaking a compliance investigation or
review or enforcement action.
What is the Notice of Privacy Practices? The Notice of Privacy Practices explains how your mental
health and medical health information may be used and or disclosed by Choices in Living Counseling
Centers, Inc. In addition, the Notice of Privacy Practices explains your rights with regard to your
protected mental health and medical health information, as well as Choices in Living Counseling Centers’
legal responsibilities under HIPPA laws.
1. Choices in Living Counseling Centers, Inc. will not share your mental health and medical health
information with others UNLESS:
1. We are required by law to do so, or
2. You authorize Choices in Living Counseling Centers, Inc. in writing to provide your mental
health and/or medical health information to specific persons or entities
Examples of persons whom you may want Choices in Living Counseling Centers, Inc. to share your
personal mental health and medical health information with: specific family members, such as
spouse or significant-other, parent(s), sibling(s), child(ren), Attorneys, other Mental Health and/or
Medical Professionals.
2. Please advise Choices in Living Counseling Centers, Inc. in writing if we can leave appointment
information on your personal (non-work) voice-mail(s), answering machine(s), email(s), Iphones,
IPADS, computers, or other electronic devices.
3. Please advice Choices in Living Counseling Centers, Inc. in writing if we can leave mental health
and/or medical health information on your work voice-mail, work computers, or other work
electronic devices?
Choices in Living Counseling Centers, Inc. HIPPA COMPLIANCE OFFICER: Shannon Howell 303 669-842
July 19, 2011 By placing an X in the box at the left, I hereby signify that I have been provided with either
x
a paper or electronic copy of the above HIPPA Rules and Choices in Living Counseling Centers, Inc. Notice of Privacy
Practices.