CONNECTIONS CORRECTIONS
111 W. Broadway Street
Butte, MT 59701
Phone: 406.782.6626 Fax: 406.782-6676
Application For Admission
This application is to be completed, in its entirety, by those persons who wish to enter and participate in the Connections Corrections Treatment Program (CCP). Please complete all questions and areas to the best of your ability. A note to the referent, if you could review this application upon its completion to check for accuracy, the screening process will be expedited. Incomplete, missing, unclear, false, or misleading information on the application will be cause for rejection of admission, and it will be returned, thus delaying possible admission into the CCP.
Are you aware that the CCP is a very intensive, sixty (60) day Residential Chemical Dependency Treatment facility, that also includes a great deal of cognitive restructuring, thus requiring complete participation and commitment? ____Yes____No
Are you also aware that State of Montana Department of Corrections (MDOC) referrals are required to personally contribute $7.00 per day ($420.00 total) to pay for room and board costs?____ Yes ____ No
Having the understanding of the demanding schedule, structure, and costs involved, in addition to the knowledge that should you be removed from CCP due to disciplinary reasons, the MDOC or the Federal Correctional Authorities can place you at a higher level of custody, are you willing to make a commitment to participate fully in CCP? ____ Yes ____No
If the answer to the questions above is "Yes", please to continue the application below.
Name of Referring Officer or Person: ______
Phone Number: ______Location: ______
For screening purposes, please indicate the best time for us to contact you or the name of another officer who may also assist in the screening process in your absence:
______
______
Part 1
Client’s Name: ______AO#: ______
Last First Middle
Date of Birth: ____/____/____ Current Age: ______SS#: _____-____-_____
Place of Birth: ______
Current Legal Charges (On your Court Judgments): ______
______
Length of Sentence: ______Sentence Date: ______
Are you in the process of having a Suspended or Deferred sentence(s) revoked?___Yes ___No
Is your sentence being revoked due to continued substance use? ___Yes ___No
Approximately, when, what, and how much did you consume? ______
______
______
What is (are) your drug(s) of choice?
1. ______2. ______3. ______
When you use, how much do you usually use per day? ______
Method of use (check all that apply)?___Drink___Snort___Drop___Smoke___Shoot
Do you have a problem with gambling? ___ Yes ___ No
Or do you just gamble while you are high/drinking, and don’t consider it a problem? ___Yes ___No
Have you ever been treated for a Gambling Addictions? ___Yes ___No
Have you ever been to an inpatient or residential treatment (like MCDC)___ Yes ___No
Treatment Provider Completed: Yes No Approximate Date of Discharge
______
______
______
Have you ever been to an Outpatient Treatment Program? ___ Yes ___No
Treatment Provider Completed: Yes No Approximate Date of Completion
______
______
______
______
How long after your last treatment did you stay clean/sober? ______
How did you accomplish that? ______
______
What was your longest period of abstinence from chemicals? ______
______
What do you see as the main cause(s) of your inability to stay clean/sober? ______
______
Do you have any past AA/NA experience? ___Yes ___No
If yes, did you have a sponsor? ___Yes ___No Did you work the Steps? ___Yes___No
Have you ever received a Mental Health Diagnosis from a Mental Health Professional?___Yes ___No
If the answer is No, skip to Part 2
If the answer to above was yes, please indicate what that diagnosis was, the person who made the diagnosis, and the approximate date of the diagnosis. This is extremely important information! You may qualify for the State of Montana’s Mental Health Services Plan, and your medications etc. could be paid for by DPHHS.
Disorder Person Making Diagnosis Location Approximate Date
______
______
______
______
Have you ever been eligible to receive or have you ever received Medicaid, Medicare, or SSDI benefits prior to your
incarceration? ___Yes ___No
Did you receive any Medicaid or Medicare benefits due to one of the above-listed disorders? ___Yes___No
Have you ever been involved with the Montana Mental Health Services Plan (MHSP) at a Montana Community
Mental Health Center such as Western Montana Mental Health, Golden Triangle, etc. for a Mental Health Condition
other than substance abuse? ___Yes ___ No
If yes, please indicate which facility and who treated you: ______
______
Please list the number of dependents you claim on your last taxes: ______
Income on last taxes: $______(This is for mental health medication assistance purposes only.)
Are you currently taking any prescribed medication for a Mental Health condition? ___Yes___ No
If yes, please list the name of the medication, dosage, and frequency:
Name of Medication Dosage Frequency
______
______
______
Are you currently suffering from an eating disorder? ___Yes ___No
Are you currently experiencing thoughts of self-harm? ___Yes ___ No
Part 2
Are you currently being treated for any Medical Conditions? ___Yes ___No
If the answer above is Yes, please list what your condition is and how often you see a medical professional for this condition?
______
______
List the name and address of the Medical Professional who you are receiving treatment from regarding this/these condition(s).
______
______
Would any of these conditions interfere with your treatment at CCP? ___Yes ___No
If yes, which condition? ______
The following is a list of the most common medications (but not limited to) that are NOT allowed at Connections. Should you be currently taking any of these medications, you should taper off of these meds under a Medical Doctor’s care.
1. Any form of Narcotic Pain Medications. Some examples are: Lortabs, Percodan, Percoset, Oxycodone, Oxycontin, Methadone, Codeine, Morphine, etc., including all generic forms.
2. Any form of Sedatives or Tranquilers. Some examples are: Xanax, Valium, Klonopin, Clonazepam, Diazepam, Paxipam, Halazepam, Lorazepam, Oxazepam, Prazepam (Anything that ends in pam).
3. Any type of Sleeping Pill or Sleeping aid. Trazodone, Desyrel, Amitriptyline, Sonata etc.
4. Any form of Muscle Relaxant: Soma, Carisoprodol, Flexerile, Cyclobenzaprine, etc.
The above list is not the complete list of addictive prescriptions that are the most common not approved medications. We cannot treat your addictions if you are taking addictive medications. Also, if the CCP screening committee does approve you for treatment, and you are taking any approved medications (considered on a case by case basis), then you must have, either a 60-day supply of these medications, or a current prescription of approved medications and the financial means of filling such prescriptions.
Please note: CCP does not have a Licensed Medical Practitioner on staff, so should you arrive at CCP, while taking a non-approved medication, which requires a Licensed Medical Practitionerto facilitate a taper, DOC will move you to either MSP or WSP, where they have the appropriate medical staff, and you will have to re-apply for CCP.
Connections Corrections usually has a waiting list for admission and the time frame for availability of an admission date does vary. The admissions staff at CCP understands that many clients do 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 Connections Corrections 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.
______
Signature Date
______
Address Phone where you can be reached
The following two (2) pages are Consent for Release of Chemical Dependency and Medical Information.
PLEASE JUST SIGN AND DATE (on the x’s) AND HAVE A WITNESS SIGN AND DATE THESE RELEASES. DO NOT CHECK ANY OF THE BOXES OR WRITE ANY OTHER INFORMATION ON THE FORMS!
Connections Corrections Program
111 W. Broadway Street
Butte, MT 59701
406.782.6626Fax 406.782.6676
I, ______, authorize the exchange of information between
(Print Full Name)
the Connections Corrections Treatment Program and the following treatment provider:
______
Name of Provider Address
______
Telephone Number Fax Number
The following two (2) pages are Consent for Release of Chemical Dependency and Medical Information.
PLEASE JUST SIGN AND DATE (on the x’s) AND HAVE A WITTNESS SIGN AND DATE THESE RELEASES. DO NOT CHECK ANY OF THE BOXES OR WRITE ANY OTHER INFORMATION ON THE FORMS!!!!!!!!!!!!!!
Connections Corrections Program
111 W Broadway ST
Butte, MT 59701
(406) 782-6626 Fax (406) 782-6676
I, ______, authorize the exchange of information.
(Print Full Name) between the Connections Corrections Treatment 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 Connections Corrections Program
____CD Evaluation results and recommendations
____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 One Hundred and Eighty (180) days from the date listed below.
X______
Client Signature Date
______
Witness Signature Date
Connections Corrections Program
111 W. Broadway Street
Butte, MT 59701
406.782.6626Fax 406.782.6676
Request For the Release of
CONFIDENTIAL MEDICAL RECORDS
I, ______, authorize the Nursing Staff of the CCCS' Connections Corrections Program
Printed Full Name
to release or receive medical information from my medical records.
______
Name of Medical Provider AddressFax or Phone Number
Name: ______
Date of Birth: ______/______/______
Social Security Number: ______-______-______
Type of Information to be released: ____ Verbal ____Written
The purpose of the release/exchange of records/information is for the Transfer of Care
To be released: ____ Progress Notes ____ Lab Reports ____X-Rays ____Med Records
____ Physician’s Orders ____Other ______
This information is requested by the Nursing Staff of the Community, Counseling, and Correctional Services, Inc., and should be Faxed to: (406) 782-6676, or mailed to the above address.
Attention: CCCS, Clarine Hettick, Nursing Supervisor
X______
Client’s SignatureDate
______
Witness’ SignatureDate
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 One Hundred and Eighty (180) days from the date listed above.
CONNECTIONS CORRECTIONS CLIENT
PERSONAL POSSESSIONS LIST
1. Clients are allowed to have in their possessions the following items. Items that are not on this list will not be allowed and will have to be sent out at your expense, or placed in storage providing we have enough room. We are not responsible for items in storage.
o Seven (7) changes of regular clothing that are gender specific and appropriate for wear here including shirts, blouses, pants, underwear, and socks.
o Two (2) pair of shoes.
o One pair of shower shoes (highly recommended) and/or slippers.
o Winter or spring coat or jacket.
o A bathrobe and/or pajamas.
o Hair dryer.
o Electric razor.
o Wedding ring or band.
o Wrist watch.
o Religious medallions/cross (if no larger than 2" x 2").
o AA/NA Big Book, "Daily Reflections," or any other AA/NA Conference approved literature (including pamphlets) will be allowed.
o One Religious Book will be allowed.
o U.S. postage stamps.
2. You may bring the following personal hygiene products, provided that they are sealed (not opened). The items that you bring will be screened prior to you receiving them. We do our shopping for Butte clients at Albertsons or Osco Drug. If you are going to have items sent to you, it is much easier for you to receive an Albertsons or Osco gift card and we can purchase the approved items for you. The following are the items that we allow to be sent in or for you to bring in at CCP.
o Shampoo and conditioner: Treseme, Dove, VO-5, Head & Shoulders.
o Lotion: Jergens, Vaseline, Nivea, Albertsons or Osco Brand.
o Deodorants (solid only, CCP does not allow spray).
Females – Sure, Arid, Secret, and Dove.
Males – Speed Stick, Axe, and Old Spice.
o Bar Soap: Dove, Zest, Lever, Clear Germ-X, Albertsons or Osco Brand.
o Body Wash: Dove, Clean & Clear, Soft Soap, Albertsons or Osco Brand.
o Toothbrush and toothpaste
3. An inventory/search of all clothing and personal items will be conducted upon entry into the program.
4. Any item(s) not listed above will be considered contraband. According to CCCS Policy and Procedures, all contraband will be confiscated and disposed of upon your admission.
5. Clothing that is suggestive, revealing, or any clothing that displays alcoholic beverages, drugs or inappropriate logos or offensive sayings will not be allowed. Shorts (except for sleep only), cut-off’s, spandex, stretch pants, dresses etc. will not be allowed.
6. Clients are to be fully-dressed, including appropriate undergarments, at all times including wearing undergarments.
7. Magazines, radios, clocks, TV's, I-Pods, CD/Tape Players, or computers are not allowed.
8. CCP has a very limited supply of coats and jackets. Please try to bring one in or have one sent in as soon as possible.
9. CCP, at the current time, does not allow tobacco usage at either of its facilities.
10. With the exception of wrist watches and wedding bands/rings, any form of jewelry will not be allowed. CCP is not responsible for the clients' jewelry if they bring it in.
11. Make up of any kind is not allowed.