Pre-Assessment

Name: Ray Rapaglia on A&E's 'Intervention'
Uploaded: 2017-08-15
Duration: 58 s
Description: Ray R. Speaks about the devastating effects of the Flakka epidemic on Season 15 Episode 21 of 'Intervention'.

James ClubRecovery Program

Guest Name*
Phone number*
Guest Type*
Referring Entity*
Case Manager*
Phone #*
DOB*
MM slash DD slash YYYY
James Club Mgr*
How did you find out about James Club Recovery? (Who referred you?)*
If being referred by Treatment Center, what level of care are you currently on (PHP or IOP)? How often do you go during week?*
Do you have a valid ID and a social security card? Copies are not acceptable (As this will make you more employable)*
Are you currently working or have a job lined up? When was the last time you held a job? For how long?*
There is a one time non refundable $200 admin fee and the weekly rents start at $180. You would need a minimum of $ 380 to come in. How do you plan on paying? (EXPLAIN GRACE PERIOD REQUIREMENTS- ONLY IF THEY NEED IT, not something we offer right away)*
Do you have any family that would help you with the rent and the basic necessities you need to get you started here?*
Have you ever been diagnosed with any mental disorder? If yes, type of disorder? When & where have you received treatment?*
Have you struggled with drugs and/or alcohol?*
When was the last time you used/what was your drug of choice?*
What would be in your system when we test you?*
Have you ever been to detox/treatment? If yes, where? How many times?*
Are you taking prescription medications? If yes, which ones?*
MAT CLIENT ONLY: What is the current dosage and intervals for this/these medications?
MAT CLIENT ONLY: Why were initially put on this/these medications?
MAT CLIENT ONLY: How long have you been on this/these medications?
MAT CLIENT ONLY: What was the dosage and intervals when you first started to take this/these prescription medication(s)?
MAT CLIENT ONLY: Do you currently have a health care provider? If yes, what is the name of your health care provider? Phone Number? When was your last appointment? Do you have a next appointment scheduled? If no current health care provider, have you contacted or setup an appointment with a local health care provider for an evaluation?
MAT CLIENT ONLY: What is your current health care provider’s plan for tapering you off the medication?
MAT CLIENT ONLY: If long term use of the medication is required what is the reasoning behind it, and can you provide documentation?
MAT CLIENT ONLY: Is the health care provider using any other medication in conjunction with this? If so please provide the health care provider’s reason behind its use.
MAT CLIENT ONLY: Are you required to attend outpatient meetings? If so, how many days/week & time frame?
MAT CLIENT ONLY: Would you be willing to sign an ROI (Release of Information) for your health care provider that prescribes your medication? DATE OF BIRTH? EMAIL ADDRESS TO SEND ROI AS DOCUSIGN?
Do you have any open warrants? (RAY CAN HELP YOU)*
Are you on supervision, Pre-trial or probation? If yes, Who is your judge?*
What other Sober/Halfway houses have you been in? What happened, why did you leave? IF YES: What will you do differently this time, at James Club? Contact Sober/Halway house to verify reason for them to no longer be there*

Pre-Assessment

James ClubRecovery Program

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