EXODUS TRANSITIONAL CARE FACILITY, INC.
APPLICATION & AGREEMENT
These services may be grouped under one or more of the following classifications:
1) Health Care Monitoring; 2) Information and referral; 3) Leisure Time Services; 4) Supportive Home Care; 5) Counseling Services; 6) Transitional Services.
A comprehensive description of these classifications of services can be found in the Exodus House program statement posted on the agency bulletin board.
The per diem rate for these services is $(please call for current rate) and does not include any services provided me by any other agency or business. Payment for Exodus House services shall be made by the Unified Services Board of my county of residence or by myself or another third party payee of my choice. As part of my treatment plan I agree to set up a structured budget and pay a percentage of the total monthly charge at Exodus House if I am able to do so. Such payments shall be due as stated in my financial agreement. It shall be my responsibility to pay for all services arranged with my permission with any agency or business other than Exodus House.
In the event that a prepayment is made and I am discharged before all funds are depleted it shall be the policy of Exodus House to charge the full per diem rate to the nearest regular business day and refund the balance.
CRITERIA FOR ADMISSION
1. Must be free from communicable disease and furnish proof of this, on or before admission. This may be a TB skin test or chest X-ray and cannot be more than 60 days old at the time of the admission. It must also include a statement from a doctor stating that they are also free of other communicable diseases.
2. Must be ambulatory.
3. Sufficient motivation conducive to change. Must be physically, psychologically, and emotionally capable of securing and maintaining employment or participation in a structured training program.
4. Maintenance of sobriety.
5. Acceptance of rules and regulations of the residence as well as application and agreement.
6. Willingness and ability to participate n the program.
7. Consent to release of information about previous treatment including medical and social history.
8. Any resident on prescribed medication must furnish the doctor's order prescribing same, for our records. Medications will be placed in a centrally located secure area and residents will self administer their medications when needed.
Random drug and alcohol screens may be performed any time a staff members suspects me of using any mood altering chemicals. Failure to comply with these screens can result in termination of residency.
I also understand that no nursing, medical, or other professional services are provided by Exodus House and that subject to the house rules and regulations, I am a tenant at sufferance on the premises for rehabilitation and the purposes of the house.
PERSONAL BELONGINGS
In the event that any personal belongings are left by a resident after discharge, such belongings shall be held for 60 days after which time they shall become the property of Exodus House.
I,______________________________________________, certify that I have read, received and have had fully explained to me the following Exodus House rules, rights, and responsibilities, policies and procedures.
Dated_____________________________
Signature of Resident___________________________________________
Signature of Facility Representative___________________________________________
Exodus 05/08