Saving Lives One Miracle at a Time

Application For Admission "Saving Lives One Miracle at a Time"

At Angels in Flight, the goal is permanent recovery from drugs & alcohol, success, wellbeing, and happiness in life. In order to achieve that goal, we ensure a safe, structured environment where all residents have the opportunity to succeed.

We provide a safe sober living environment for single women and women with children. We are involved bible based meetings and studies we also attend 12 step meetings such as AA/NA / and Celebrate Recovery meetings. We attend outside and in-house meetings. Clients are required to attend 5 mandatory meetings each week. They have to obtain employment or become involved in service work. The clients are required to obtain a sponsor and work the 12 steps of recovery. The first steps are worked with a counselor at our facility. We provide recovery classes on identifying triggers, relapse prevention, character traits (good and bad), and family dynamics, dysfunctional families, relationships, anger management, how to maintain and balance budgets, etc.

Angels in Flight Recovery Center, Inc. is committed to providing a comprehensive system of care that sustains long term recovery from addiction and mental illness.

Overview of Services

12-Step Education / Groups Bible Based Meetings Alcohol and Drug Prevention and Education Case Management Employment Services Toxicology Screening Transportation Services

Our Minimum Requirements for Admission to Angels in Flight 1. Commitment to stay at least 6 months. You may stay longer. 2. Complete abstinence from all mind & mood altering substances. This includes drugs, alcohol, prescription drugs (certain medical exceptions can be made), etc. We do drug & alcohol screening 2-3 times per month and screens may be sent to the lab for verification. We ensure that you will have a safe and sober place to recover, and we discharge immediately with zero tolerance for a failed drug or alcohol screen. 3. Willingness to learn how to stay clean & sober through the 12 Steps of Recovery. 4. You must be willing to get a “sponsor”, which is a person who will guide you through the 12 Steps of recovery. We expect everyone to have a sponsor within 3 weeks. One-on-one work with a sponsor is the most important part of your recovery. We will help you learn what to look for in a sponsor, and assist you in finding one if needed. 5. Willingness to explore your spiritual self. We understand that addicts and alcoholics are spiritually sick, and the 12 Step Program offers a solution that will heal mind, body and spirit. 6. Complete willingness to follow all rules and directions. Angels in Flight is a structured living environment that provides all residents with the opportunity to live life to the fullest, but learn to live with structure and accountability. We will discharge anyone who does not follow the rules, for the safety and wellbeing of those who are serious about long term recovery. 7. You must either have a job, be a full-time student, or be attending an outpatient program. If none of these are your current situation, you will be on an intensive job search from 9am to 4pm. In special, pre-approved cases, participating in verifiable, full-time community service or volunteer work may be acceptable. Part of the structure of recovery is learning to fill our day with worthwhile and productive activities. Even if your program fees are being paid by family or outside resources, you will be required to be productive and self-sufficient at Angels in Flight.

Angels in Flight is not for everyone. We are not the place for someone who is not 100% serious about long term success. We interview each potential resident and assess their willingness, character, and determine whether or not they will be a good fit for our program. In the event that Angels in Flight is not the place for you, then we will give you referrals to other programs that may be more suitable. Admission Fee: There is an entrance fee of $200.00 upon admission. (Non-Refundable) Monthly: $600 per month, due between the 1st and the 5th of each month. There is an additional $150.00 fee for food cost, unless you qualify for our food stamp program. Your first month will be due at intake along with the entrance fee as well as the food cost. A late fee of $50.00 will be added if the payment is not received by date due. The following documents are needed at intake: Social Security card, Photo ID, birth certificate, current proof of TB skin test and RPR results. If these documents are not obtained prior to arrival of intake with client, monies have to be left in order for us to help obtain these documents. Bed Holding Fee: In the event that we have an open bed available, but you need us to HOLD it (it will be unavailable for anyone else), there is a $100 per week fee to hold the bed. This fee is non-refundable and is not applicable towards program fees. If you are on medical leave you have to pay a $100.00 a week fee for each week that you are out (starting the day you leave) $100.00 will have to be paid on the day you leave, this fee is non- refundable and is not applicable towards program fees. ALL PROGRAM FEES ARE NON-REFUNDABLE Monthly Program fees include housing, utilities, drug and alcohol testing, and administrative costs.

Penny Foskey (CEO/Director) [email protected]

478-864-8090 (phone) 478-864-6334 (fax) www.angelsinflight13.org

[email protected] Lisa Coward INTAKE COORDINATOR

PO BOX 352

WRIGHTSVILLE, GA 31096 Angels in Flight Recovery Center/Apostles House

Saving Lives one miracle at a time

CLIENT INFORMATION (Please print CLEARLY and complete)

Name:______Last First Middle

Age: _____ Date of Birth: __/__/___ Place of Birth: ______Race: ______

Marital Status: S M W D Social Security Number: ______-_____-______

Permanent Address: ______

City: ______State: ______Zip Code: ______

Phone/Home: ______Phone/Work: ______

Current Driver’s License #: ______

Do you have current auto insurance coverage: ______Clients are required to have current driver’s license, current registration and auto insurance if they will be operating a motor vehicle while a client of Angels in Flight, Inc. ______

Spouse/Next of Kin: ______Relationship______

Address: ______City/State/Zip Code______

Phone/Home: ______Phone/Work: ______

Emergency Contact: ______Relationship: ______(Clients must sign a release for this person)

Address: ______City/State/ Zip Code ______

Phone/Home: ______Phone/Work: ______Angels in Flight Recovery Center

Were you mandated to treatment? ______If yes, Explain:______

______

Do you have legal charges pending? _____ if yes, Explain: ______

______

Probation Officer Name: ______Phone#: ______

Address: ______City/State/Zip Code: ______

Attorney/Legal Representative Name: ______

Phone # ______Fax # ______

Do you have any physical limitations? ______

Profession: ______Name of Employer: ______

Start Date of this Employment: ____/____/_____ Is your job in jeopardy:______

Employer Contact/Supervisor: ______Phone #: ______

Company Address: ______City/State/Zip Code: ______

Education: Total years of school: ______Level completed: ______

How did you hear about Angels in Flight Recovery Center, Inc.? ______

______

______Client Signature Date Please write a one page essay on what are your expectations of Angels in Flight Recovery Center, Inc. Why did you choose us? What do you expect to gain from your stay with us? How did you hear about Angels in Flight?

______Angels in Flight Recovery Center, Inc.

Saving Lives one miracle at a time Prescribed Medications List

NAME: ______DATE:______

Medication Name Dosage How Often Doctor’s Name

Angels in Flight Recovery Center, Inc.

Saving Lives one miracle at a time OTC Medications List

NAME: ______DATE:______

Angels in Flight Recovery Center Saving Lives one miracle at a time

FEE FOR SERVICE AGREEMENT

Angels in Flight Recovery Center, Inc. is a non-profit agency dedicated to providing safe, structured recovery residences, based on community living and the 12-step program for individuals seeking recovery from alcohol and drug addiction. The undersigned acknowledges, accepts and understands that they are living in an alcohol and drug free shared recovery residence. The undersigned also acknowledges that residency is in the capacity of a lodger sharing a housing unit and not as a tenant with rights or possession of space exclusively.

This is a contract between ______(sometimes referred to as a “client” or “resident”) and Angels in Flight Recovery Center, Inc. this ______day of ______, 20______.

____The client agrees to pay a $______NON REFUNDABLE ADMISSION FEE and a monthly fee of $______per month, for residential recovery services provided by Angels in Flight Recovery Center, Inc. Client agrees to pay fees for service on a monthly basis due the 1st day of each month. ALL PAID FEES ARE NON REFUNDABLE. There is a late fee of $25 if fees are not received by 8:00 pm on the 1st day of the month.

____The client agrees to pay a $______NON REFUNDABLE ADMISSION FEE and a weekly fee of $______per week, for residential recovery services provided by Angels in Flight Recovery Center, Inc. Client agrees to pay fees for service on a weekly basis due each Friday, for the FOLLOWING week. ALL PAID FEES ARE NON REFUNDABLE. There is a late fee of $15 if fees are not received by 8: pm on Friday for the following week.

____ The client agrees to pay a $______REFUNDABLE DEPOSIT at time of intake, deposit will only be refundable if client completes program. Successful 180 day completion.

Angels in Flight Recovery Center, Inc. agrees to provide the following services:

● 24 hours/7 days a week on call supervision. ● Random drug screens. ● Weekly facilitated recovery meetings. ● Weekly sober living skills classes. ● Provide a safe, secure and supportive sober living situation.

The undersigned acknowledges and understand that failure to comply with Angels in Flight Recovery Center, Inc. house policies, rules and expectations is grounds for immediate discharge.

The undersigned acknowledges that non-payment of fees and/or failure to maintain a current paid status on any fees associated with the participation in the Angels in Flight Recovery Center, Inc. services will result in discharge. The undersigned acknowledges that management reserves the right to terminate this agreement and residents are required to provide a thirty-day written notice of intent to leave the recovery residence. The undersigned

Fee For Service Agreement, Page 2

also acknowledges that in the event of discharge from Angels in Flight Recovery Center, Inc., the resident shall immediately vacate the premises, turn over possession of any and all keys, and shall remove all personal property. The removal of personal property shall be arranged and supervised by assigned staff.

1. As a client/resident of Angels in Flight Recovery Center, Inc. I knowingly and willingly waive my rights to privacy and to be secure in my person and property. I also permit and authorize Angels in Flight Recovery Center staff to search my property, person and living area, without probable cause of any suspicion of any possession or use of any substance. 2. I have read the above agreement and agree to follow the Program/House Policies, Rules and Expectations as outlined above. It is my Responsibility to know what the Program/House Policies, Rules and Expectations are. 3. I understand that management is here to help me follow a program of recovery and to provide a safe, structured living environment. I understand that being confronted on my behaviors from a caring point of view is part of participation in this program. 4. I understand that failure to process (discuss) adverse or undesirable behaviors and make adequate changes in such behaviors will immediately result in discharge. 5. I understand that by signing this agreement, I release Angels in Flight Recovery Center, Inc., staff, management, volunteers and /or Board of Directors from any and all liability during my participation, or resulting from my actions, or actions of others while a resident of Angels in Flight Recover Center, Inc.

Resident’s Printed name: ______

Resident’s Signature: ______Date: ______

Angels in Flight Recovery Center, Inc. Representative

Signature: ______Date: ______

Title: ______

Witness:______Date:______Angels in Flight Recovery Center

AUTHORIZATION FOR RELEASE TO COMMUNICATE

NAME OF CLIENT ______

I hereby request and authorize Angels in Flight and it’s representatives to disclose information to, and discuss my participation in Angels in Flight program with the following people:

Name: ______

Phone: ______

Relationship: ______

Email: ______

Name: ______

Phone: ______

Email: ______

Name: ______

Phone: ______

Email: ______

______

Signature of Client Date Witness Signature Angels in Flight Recovery Center

Authorization for Services

I ______, do hereby voluntarily consent to services provided by Angels in Flight, including residential services, consultation, and therapeutic services. Failure to participate in recommendations may result in termination or referral to other setting of care.

Treatment is a team approach and information will be shared among staff and any other designated agent. The team will include any volunteers, professionals, or contracted persons who are in the network with Angels in Flight, in order to provide services for you or your condition. No information will be released outside the treatment team without express written consent.

I give consent for the team to share information about me and my substance abuse or mental health records in order to provide me treatment services.

I understand that I must provide truthful information regarding my medical and legal status. I understand the Angels in Flight will not harbor fugitives from the legal system.

I hereby certify that I have read and fully understand the above Authorization.

______

Signature of Resident Date Angels in Flight Recovery Center

AUTHORIZATION FOR RELEASE OF INFORMATION

NAME OF CLIENT ______

SOCIAL SECURITY NO. ______DATE OF BIRTH ______

I hereby request and authorize:

To disclose to or obtain from: Angels in Flight Recovery Center, Inc. 2041 West Elm Street Wrightsville, Georgia 31096 Bus. (478-864-8090) Cell (912) 659-9423) Fax. (478) 864-6334)

The following type(s) of information from my records (and any specific portion thereof): History and Physical exam ____, Alcohol and Drug Abuse Treatment records _____, AIDS related information including results of HIV testing _____, TB (tuberculosis) _____, STD (sexually transmitted disease) _____, Other:______

For the purpose of the authorized disclosure herein is to be (be specific): ______I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patients records, 41 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV related information about me, STD related information about me, and TB related information about me is protected by State law and cannot be disclosed unless the disclosure is authorized by State law. I also understand that I may revoke this consent, in writing, at any time except to the extent that action has been taken in reliance on it, and that in any event this consent automatically expires as follows. If you wish to discuss revoking this authorization or refuse to sign this form, you can ask for assistance from your Therapist or Program Director who can go over this information in more detail: _____ Ninety (90) days unless I specify an earlier expiration date here: ______One (1) Year _____ The period necessary to complete all transactions on accounts related to services provided to me.

Angels in Flight Recovery Center

AUTHORIZATION FOR RELEASE OF INFORMATION

(Page 2)

_____I give permission to communicate with the above person/facility by e- mail.

______Signature of Client Date Witness Signature

______Signature of Parents or Authorized Rep. (If under 18 or if required)

Use this space Only If Client Withdraws Consent

______Witness/Title Date Signature of Client Angels in Flight Recovery Center, Inc.

CLIENT CONFIDENTIALITY AGREEMENT

The confidentiality of recovering persons living in a Supportive Living Environment is protected under Federal Law 42 CFR, which protects them from anyone outside of the program having knowledge of their participation in the program without the client’s specific permission. No information regarding a client of Angels in Flight may be release to anyone outside of the program unless:

1. The client has signed a consent form to that person/agency; 2. A court order is issued to Angels in Flight regarding information on the client; 3. Medical personnel require the information in a medical emergency, or; 4. The client threatens to harm him/herself or someone else.

Federal Law does not protect a client if they commit a crime against anyone at Angels in Flight. Also, Federal Law does not restrict sharing information regarding reported child abuse/neglect to appropriate State and local authorities.

The laws apply not only to the staff, Board and volunteers of Angels in Flight, but to the clients as well.

I agree to not reveal to anyone outside of the Angels in Flight program, the name identity, or description of another client. I also agree to not discuss the content of conversations of groups with anyone outside of Angels in Flight. This includes sharing at 12-step meetings.

I agree to inform staff if any of my peers reveal any information about themselves or another client that may be a cause for concern.

______

Client Signature Date

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Staff Signature