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FIRST at Blue Ridge, Inc.Information for Applicants No violence, threats of violence or use of drugs/alcohol will be tolerated at the FIRSTprogram.You will be discharged and the proper authorities will be notified.The preppie phase will last 30 days or until initial treatment plan goals have been met,depending on how you work the program. During the preppie phase, between the hoursof 6:30 AM – 9:30 PM, clients will be scheduled a variety of activities including educationalclasses, group therapy, 12-step meetings, work assignments, chores etc.During the first 30 days, you are allowed 1 brief phone call to family upon arrival. Afterpreppie phase, three 15 minute phone calls to approved numbers are allowed per week.After the preppie phase, residents can earn a day pass every 30 days.You may be eligible to go on a home visit after (90) days for 4 days and 3 nights,depending on how well you are doing in the program.Do not bring cash. However, credit cards and debit cards are okay, but will be stored in theadministrative office, not kept on the clientDo not bring computers, cell phones, TVs, stereos, weapons, pornography, and clothingwith alcohol/drug symbols or profanity.Do not bring any tight fitting or revealing clothing.All clients will receive a work assignment after completion of the preppie phase in order tohelp support the House. These will be based upon client skills, House needs and othercriteria.You must use the chain of command if you have any questions. If you need anything, askyour Peer Leader or House Manager.Be humble and do what is asked of you. If you have a problem with something you areasked, do it anyway and then follow the chain of command in order to let someone knowhow you feel about what you were asked to do.By signing below, you are confirming that you have been made aware of these rules during theApplication process, and if accepted into the program, agree to abide by them.Applicant’s signature Date18

FIRST at Blue Ridge, Inc.Items to Bring ADMISSION FEE (ONLY-cash, money order, cashier’s check. NO PERSONAL CHECKS)The personal items should be kept to the following: 10 pairs of pants (including 1 or 2 pair of slacks) This cannot be tight fitting 10 shirts (including 1 or 2 dress shirts) This cannot be tight fitting 10 t-shirts. This cannot be tight fitting 2 dresses 1 suit 1 pair of pajamas or 1 nightgown/1 robe 1 pair of slippers 1 pair of flip-flops 1 purse AND wallet Make-up and jewelry (Make-up & jewelry will NOT be worn for the first 30 days) Necessary toiletries/hygiene items 10 pair of underwear, 10 pair of socks, 5 bras 1 large winter coat 1 jacket 1 AA Book / 1 NA Book 1 Bible 1 Journal NO more than 3 pair of shoes, 1 pair of slip resistant work shoes/boots REQUIRED Black Pants AND Khaki Pants *REQUIRED NO more than 2 hats ID – Social Security Card, Picture ID Ear plugs Physician’s orders for medications Clients MUST have a 30 day supply and AT LEAST a 90 day refill for medications in order to gainacceptance into our program. Client is responsible for cost of refills and new medications. Gloves (work/casual) Laundry bag Alarm clock Electric razor or disposable razors Writing paper/notebooks Pens/pencils Envelopes/stamps Veterans Identification (if eligible: DD-214 form is required) Court document(s) if probated/court orderedIf you do not have all of the above items, we will do our best over the following weeks to assurethat you receive the clothing items you require.19

Items NOT to bring: Tight or revealing clothingWeapons (real or fake)Anything containing alcohol (cologne, mouthwash, etc.)PornographyStereos/Cell phones/Televisions/Computers/DVD playersMP3s, IPODs, and portable CD playersHair clippersDrug paraphernalia, clothing with alcohol/drug symbols or profanityStuffed AnimalsExpensive/Valuable jewelry (including earrings, rings, and body jewelry)FIRST Inc. will not be responsible for items left after a resident leaves the program.NOTE: Unauthorized items may be confiscated.I understand that if I bring items other than those specifically listed above, the items will bedisposed of at the time of my entry into the program. The list above is all-inclusive; there are noexceptions.Print NameSignatureDate20

FIRST at Blue Ridge, Inc.AUTHORIZATION TO RELEASE INFORMATION(CRIMINAL JUSTICE SYSTEM REFERRALS)Resident’s Name authorize the following:Name of program which is to exchange information:FIRST at Blue Ridge, Inc.P.O. Box 4032 Knox Rd.Ridgecrest, NC 28770Name or title of the person(s) or organization(s) with which the disclosure is to be made:Court having jurisdiction over the residentProbation and/or parole officers or their agenciesTASC referral unitsProsecuting attorney withholding charges against the residentDefense attorneyDepartment of Social Services and/or its agentsPurpose or need for the disclosure:For assessment and treatment planning; to monitor progress in treatment and compliancewith conditions of referralExtent or nature of information to be exchanged:Any and all pertinent information contained in filesThis consent is subject to revocation at any time except to the extent that FIRST, Inc. has alreadytaken action in reliance on it. If not previously revoked, this consent will terminate three hundredsixty-five (365) days after termination of treatment.Signature of Resident DateSignature of Witness Date21

FIRST at Blue Ridge, Inc.AUTHORIZATION TO RELEASE INFORMATION(GENERAL CONSENT)Resident’s Name authorize the following:Name of program which is to exchange information:FIRST at Blue Ridge, Inc.P.O. Box 4032 Knox Rd.Ridgecrest, NC 28770Name or title of the person(s) or organization(s) with which the disclosure is to be made:Family and significant others of resident; employers and potential employers;funding sources; the Department of Social Services; psychiatric, medical, or treatmentpersonnel; Social Security Administration; Food Stamp offices.Purpose or need for the disclosure:In order to provide relevant information as to resident’s treatment status or progress andfor follow-up investigation.Extent or nature of information to be exchanged:Only such information as is reasonable and necessary for the particular circumstance.This consent is subject to revocation at any time except to the extent that FIRST, Inc. has alreadytaken action in reliance on it. If not previously revoked, this consent will terminate three hundredsixty-five (365) days after termination of treatment.Signature of Resident DateSignature of Witness Date22

OVER THE COUNTER MEDICATION FORMClient/Patient Name: DOB:STANDING ORDERS FOR OVER THE COUNTER MEDICATIONSMEDICATIONTREATMENT GOALSSTRENGTHAllergy and ColdPreparationsFor relief of allergy or cold symptomsAs dispensed OTCKaopectate concentrate orGenericFor relief of loose bowel movementsAs dispensed OTCMilk of Magnesia or GenericFor relief of ConstipationAs dispensed OTCTylenol or GenericFor relief of minor aches & pains, and /or feverAs dispensed OTCIbuprofen or GenericFor relief of minor aches & pains, and /or feverAs dispensed OTCBenadryl or Generic.For relief of allergy symptomsAs dispensed OTCMultivitamin and NutritionSupplementsFood SupplementAs dispensed OTCCough and Cold preparationFor relief of cold and cough symptomsAs dispensed OTCComments:Read Carefully:By my signature below, I acknowledge that during my participation in the First at Blue Ridge, Inc. residentialtreatment program, I will take only take those over-the-counter medications listed above. Further, I agree only totake recommended doses and for the indicated uses on the over-the-counter medication packages. I recognize that itis my responsibility to review the package information, with each dose taken, for any potential adverse interactionsand contraindications to my use. Further, I hereby agree to hold First at Blue Ridge Inc., and the healthcare providerlisted below harmless if I take any over the counter medication not listed above or outside the parameters ofrecommended dosages, uses and warnings or contraindications.DatePhysician SignaturePhysician PrintClient’s signature Date Even if not on prescription medications ALL forms must be signed. 23

Medication Self Administration/SelfPossession AuthorizationSelf-administration means (the client) canadminister his/her medication in a manner directed by their physician withoutadditional direction or supervision by FIRST at Blue Ridge Inc staff. Self-possessionmeans that under the direction of the physician, the client may carry medication onhis/her person to allow for immediate and self-determined administration. Formedication other than inhalers, topical creams, patches and sprays, only that day’ssupply (24 hours) of medication is to be carried. FIRST at Blue Ridge Inc recommendsthat spare medication, properly labeled in its original container, to be kept in the FIRSTat Blue Ridge Medical Office.The client agrees to:1.2.3.4.Never share his/her medication with another personCarry the medication in a responsible manner so as not to lose itTake medication only at the prescribed/frequency and doseKeep a copy of this form and back up medication in the FIRST at Blue Ridge IncMedical OfficeIf the client fails to meet any of the agreements listed above, FIRST at Blue Ridge Incmay discontinue the Self-Administration/Self-Possession privilege without notice. IfFIRST at Blue Ridge Inc revokes the Self-Administration/Self-Possession privilege, clientmay be discharged from the program.Physician’s Printed NamePhysician’s SignatureDateClient’s SignatureDate24

FIRST at Blue Ridge, Inc.PHYSICIAN ORDERSClient:Last NameFirst NameMiddle InitialAllergies (Food, Drugs, Etc.):PRESCRIBED MEDICATION: List ALL medication prescribed by Medical Professionals INCLUDINGALL OVER THE COUNTER ITEMS. Sample Medications should be dated & marked by Physician.Clients MUST have a 30 day supply and AT LEAST a 90 day refill in order to gain acceptance intoour program.DateMedication NameStrengthAdministration DirectionsQuantity# of RefillsPhysician SignaturePhysician Print Even if not on prescription medications ALL forms must be signed. 25

AGREEMENT TO ACCEPT TREATMENT AT FIRST AT BLUE RIDGEI, (print name), acknowledge and agree to each ofthe following:As a client and participant in the long-term treatment program offered at FIRST at Blue Ridge, Iam expected to participate in work therapy assignments under the direction of FIRST staff and itscommunity partners. I understand this means that any and all situations where my ability toparticipate in work therapy as directed is compromised or otherwise affected may conflict withFIRST’s goals for my long-term treatment, and therefore such situations require FIRST’sreconsideration as to my appropriateness for the program.(initial and date)Such situations include, but are not limited to: recommendation for Intensive Outpatient Programs,medical diagnosis that affect my ability to participate in work therapy, changes in medication thataffect my ability to participate in work therapy, prescriptions for medications that are not allowedin the FIRST program, operations and surgery that affect my ability to participate in work therapy,and recommendations for treatment that conflict with, or are contrary to, FIRST’srecommendations for treatment.(initial and date)I understand and agree that FIRST makes every effort to assist with transition planning for itsclients, and that my acceptance and pursuit of other treatment recommendations may mean that mytransition would best be handled by those making such recommendations. This includes, but is notlimited to, other agencies and their personnel, family, friends, doctors, and other medical providers.(initial and date)By signing and dating below, I am acknowledging and agreeing to the above and confirming that Idesire the treatment provided by FIRST at Blue Ridge.(sign name)(date)(witness to the agreement)26

Outline for Applicant’s Autobiography“We admitted we were powerless over our addiction and that our lives had become unmanageable”It would be impossible to over-estimate the importance of being thoroughly and completely honest withyourself and others. Each client is required to write an autobiography including a history of their substanceuse, mental health issues, and goals for treatment and recovery.Issues to be covered in your autobiography are:1. Describe your substance use history including what and how long you have used.2. Have you ever been in the hospital for mental health reasons? Explain in detail.3. Have you ever tried to commit suicide?4. Discuss any mental health issues including diagnoses and history.5. List what meds you are taking and why.6. Describe your present situation – be specific as possible.7. Why do you want to be admitted to FIRST?8. Discuss specific changes you want to make in your life.9. What goals do you want to achieve while at FIRST?10. What are your goals for recovery?11. How will you contribute to the program and your fellow residents?Length: Your personal autobiography should be at least 3 to 4 pages in length, and should be neatlywritten or typed in chronological order as to how and when events occurred. Please do not write over 6pages.This autobiography is CONFIDENTIAL. At your request, it will be returned to you at time of discharge. Thisautobiography will help us determine if you are appropriate for our program and how we may best serveyou.27

FIRST at Blue Ridge, Inc. Women and Children: Application for Admission . FIRST at Blue Ridge, Inc. 32 Knox Road Ridgecrest, NC 28770 . www.firstinc.org . 1. Updated 12/3/2015. Important For this application to be considered, All forms must be filled out COMPLETELY including appropriate signatures