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Milestone Guide Beyond Families Milestone Guide February 2020 Beyond Families Table of Contents Milestone 0 (Earning your white belt- getting sober) Orientation Milestone 0 Checklist 5 Beyond Families Participation Contract 6 Consent for Re-disclosure of Confidential Information 7 Medical Compliance Form 8 Beyond Families Countdown to Sobriety Worksheet 9 Drug Testing Program Requirements 10 Classroom/Group Guidelines 11 Beyond Families Important Points to Remember 11 Client Information Sheet 12 Prescription Drug Policy 13-14 Doctors, Medicine, and Beyond Families Info. 15 Approved Over the Counter Medication List 16 2 Beyond Families Milestone 1 White Belt (30 days of sobriety plus checklist) Milestone 1 Checklist 17 Questions 1-4 18-21 Important Contact Information 22 Appointment Scheduler Worksheet 23 Plan of Safe Care Completed (Not in Workbook) What are You Strengths? 24 Taking Care of Me 25 Milestone 2 Yellow Belt (90 days of sobriety plus checklist) Milestone 2 Checklist 26-28 Questions 1-2 29-30 Making a Budget 31-34 Budget Worksheet 35-38 Transportation Cost Worksheet 39-40 Exercise Journal 41 Sleep Journal 42 Family Activity Worksheet 43-44 Shopping List Worksheet Example 45 Shopping List Worksheet 46 Program Attendance Verification Forms 47-48 Milestone 3 Green Belt (150 days of sobriety plus checklist) Milestone 3 Checklist 49-50 Question 1 51 Transportation Cost Worksheet 52 Daily Meal Planner Worksheet Example 53 Daily Meal Planner Worksheet 54-58 Leisure Activity Worksheet Example 59 Leisure Activity Worksheet 60 3 Beyond Families Milestone 4 Blue Belt (210 days of sobriety plus checklist) Blue Belt Milestone 4 Checklist 61 Questions 1-2 62-63 Transportation Cost Worksheet 64 Milestone 5 Black Belt (270 days of sobriety plus checklist) Milestone 5 Checklist 65-66 Questions 1-2 67-68 Post-Graduation Checklist and Aftercare options 69 Appendix A 211 Information Packet 70 Appendix B 71 Narcotics Anonymous and Alcoholics Anonymous Meeting Information Medical Marijuana 72-76 4 Beyond Families Milestone 0 White Belt Orientation and Introduction Drug Test Color: _____________ Completed orientation packet o Contract o Release of Confidential Information o Medical Compliance o Drug Testing Program Requirements o UA Collection o Client Information Sheet Received o Points to Remember o UA Color System o Prescription Drug Policy o Doctor, Medicine, and BF info sheet Received White wrist band Issued BF Guidebook binder Your starting date is: __________ Sober date: ___________ Your date to start drug testing is: _________ 5 Beyond Families Participation Contract I, _______________________________, have been accepted as a voluntary participant in the Beyond Families Program. I understand that if I successfully complete the program, I will have successfully completed the treatment plan regarding substance abuse and/or dependency. Initial each condition of Beyond Families Participation Contract: _____ I will complete an alcohol and drug assessment as required by Beyond Families and I will follow all treatment recommendations. _____ I will cooperate with Beyond Families Project Director and the program staff. _____ I will sign all releases needed by Beyond Families and I will allow Beyond Families to monitor diagnostic and treatment information including for my medical and mental health treatment necessary for my successful participation in Beyond Families and the safety of my child(ren). _____ I will be on time for all scheduled treatment appointments. _____ I will meet with Beyond Families personnel when and where scheduled. _____ I will call my DHS worker weekly if applicable. _____ I will comply with any modifications to my treatment plan made by Beyond Families. _____ I will submit to drug and alcohol tests on a regular basis. _____ I will engage in any education, treatment, or rehabilitation program recommended. _____ I will obtain a legal source of income. _____ I will obtain a safe and stable home. _____ I will provide Beyond Families my current address, phone number, and employment. _____ I will actively participate in Beyond Families until completion, withdrawal, or termination. _____ I understand that I will be held personally responsible for any guests in the home that may have an influence on my sobriety and the safety of my children. _____ I understand that I must complete all Milestones (1-5) before I can graduate from the Beyond Families Program. _____ I am voluntarily signing this contract with the intent of participating in Beyond Families. Program Responsibilities _____ Beyond Families will pay for all urine drug tests. _____ Beyond Families will provide support, respect, encouragement, and advocacy. ______________________ _____________________________________________ Date: Participant Signature: ______________________ _____________________________________________ Date: Beyond Families Project Director 6 Beyond Families BEYOND FAMILIES 323 W. 6TH ST. OKMULGEE, OK. 74447 CONSENT FOR THE REDISCLOSURE OF CONFIDENTIAL INFORMATION Beyond Families Program I voluntarily agree to participate in the Beyond Families Program (BF). I have read (or had read to me) and understand this Release of Confidential Information form. I, ___________________________________________________ DOB: ________________ Last Name, First Name, Middle Initial (MM / DD / YY) authorize Beyond Families and its staff to receive and redisclose information from: Drug testing results, Creoks, The Oklahoma Department of Human Services, Court Ordered Service Providers, The Okmulgee County District Attorney, court appointed counsels, and approved interns, if applicable. The purpose of and need for the disclosure is to inform the Department of Human Services, and other parties of my attendance at and progress in drug/alcohol treatment and to receive information relevant to my treatment. The extent of information to be disclosed is my diagnosis, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, my treatment plan, my progress, prognosis and my discharge summary. I understand that I may revoke this consent in writing at any time, and that in any event this consent expires automatically upon my discharge from the Beyond Families Program. I further understand that my revocation of this consent may result in my immediate termination from Beyond Families if it affects my case/treatment. Any disclosure made is subject to the Code of Federal Regulations, 42 C.F.R. part 2, and the United States Code, 42 U.S.C. § 290dd-2, governing confidentiality of alcohol and drug abuse patient records. 42 CFR Part 2 prohibits unauthorized disclosure of these records. As stated in the Code of Federal Regulations, 42 C.F.R. § 2.31, § 2.35, as a participant in Beyond Families, I have the right to revoke this consent at any time. DATE: X ____________________ X ___________________________________________ Participant Signature X_____________________________________________ Witness Signature 7 Beyond Families Medical Compliance I understand that I have been prescribed the following medication that I am currently taking while I am participating in Beyond Families. I understand that these are current drugs and I am not allowed to take anything other than what has been currently prescribed. I understand that I am to take these prescriptions strictly as prescribed to me by my doctor. Prescription Physician ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________ I understand that I am obligated to: 1. Notify any and all treating medical professions that as a person in recovery and I am not permitted to accept samples, fill prescriptions, or in any way accept any substance which is considered addictive without prior approval of my primary physician/therapist. Among the substances considered addictive are opiates, benzodiazepines, sedatives and some anti-anxiety medications. 2. Request that a non-addictive substance be prescribed in situations where a prescription is required. Should the treating professional feel it is necessary to prescribe a substance which would reflect positive on a urinalysis, it is my obligation to report this immediately to my DHS worker if applicable and BF for their records. 3. If there is a change in medication from my doctor, I need to report this change immediately. I have read and understand the following conditions of Beyond Families. Further, I agree to abide by the above conditions regarding prescription medication. ____________________________________ Print Name _____________________________________ __________________ Signature Date 8 Beyond Families Beyond Families COUNTDOWN TO SOBRIETY WORKSHEET Name: (please print) _________________________________________ Official Beyond Families Start Date: ____________________ I understand that 30 days of lack of engagement may result in termination from Beyond Families. I understand that part of the engagement process is proof of sobriety by means of drug testing. Check One: ☐ I will test negative beginning today. ☐ I will temporarily test positive for the following drugs: __________________________________________________________ Signature:
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