Microsoft word - combined adult application & supplement - short term

Thank you for your interest in Minnesota Teen Challenge (MnTC). Our program is designed to help those who are struggling with life-controlling chemical dependency issues and desire a faith-based component as part of the approach to recovery. To complete the admissions process you must complete the following steps: Have a Rule 25 assessment from the county in which you permanently reside (if you desire funding assistance). Generally, assessments must be scheduled several days in advance. To speed up the admissions process, please make an appointment now—even before submitting this application.  Complete the attached application and fax or mail it in to the location to which you are applying. If you are receiving assistance in completing this application, or want us to be able to talk to somebody else about your application, be sure to complete the attached “Release of Confidential Information” form. Phone: (612) 238-6500

Upon receipt of your application, an admissions representative will contact you and begin processing your application.
The length of the application process can vary from a couple of days to two weeks. In processing applications a
number of things are taken into consideration including: mental health, medical condition, past and present legal
status, funding eligibility, and level of care required.
MnTC is a voluntary program. Please carefully review all of the information in this packet to determine if our program is
right for you. If not, please contact our admissions office to request a referral list of other programs.
It’s important that your contact information is current. If you are submitting an application and have relocated please be
sure to notify our admissions department of your current contact information.
Important Applicant Information:
 Applicants are required to have and will not be admitted without a photo identification and social security card. If you do not have these at the time of application please begin the process to receive them before admittance. We are able to help with that process if need be.  Applicants requiring detoxification must do so prior to entry.  MnTC is NOT a medical care facility; therefore, we do not provide clients with medication or onsite access to professional physical or mental healthcare providers. Applicants are required to enter the program with at least a 30
day supply of all currently prescribed medications (with the exclusion of prohibited meds).
 A physical examination is normally required prior to admission. Some applicants may be approved for admission prior to having a physical examination, provided they agree to have a physical immediately upon entering our program. Tests for HIV, STD’s, Tuberculosis and Hepatitis are required as part of the physical exam. Residents who enter the program without having a physical exam and those who do not have medical insurance will be charged $5 for a Tuberculosis test upon admission into the program.
Thank you again for your interest in our program. We look forward to the opportunity to help you in your recovery from
drug and alcohol addiction.

Please return only the Application, Voluntary Compliance with Faith Based Activities document, and
Release of Information form to the admissions office. The other materials are for your records.



First Name:
SSN: _______-_____-_______ Sex:
Middle Name:
Last Name:
DOB: ____/____/____

Current Address:
Height: _____ Weight: _____
Legal Resident Of:

Do You Have Any Relatives Or Friends Currently In Our Program?
No Who? _________

Have You Previously Been In Our Program?
How Many Years Ago? _________
Marital Status:

Citizenship:

Do You Read And Write English At A 5th Grade Level or Above:
Do You Have A High School Diploma?
No If No, Do You Have A GED?

I Mainly Need Help With: (Check All That Apply)

Do You Use Tobacco?
No (Tobacco use is not permitted at any time while enrolled in the program)
Have You Ever Been Treated For Chemical Addiction?
Prior Treatment Facility: (list the most recent treatment program you have been in)
Address: ____________________________________________ City: Dates of Treatment: ____/____/____ to ____/____/____ Reason for Treatment:
In your own words, tell us why you want to come to Minnesota Teen Challenge and the main issues you believe you
need to deal with while in the program: (Please print clearly)


PHYSICAL HEALTH
Please be advised that MnTC is NOT a medical care facility; therefore, we do not provide clients with
medication or onsite access to professional physical or mental healthcare providers.

Medical History: (Check all that apply to your current and past conditions)
Do you have any current medical concerns? If yes, please be specific:_______________________________________
__________________________________________________________________________________________________
Are you currently being treated by a doctor?

Name of Primary Doctor:
Dates of Treatment: ____/____/____ to ____/____/____ Reason
Are you pregnant?

Are you allergic to any medications?
No If Yes, what medications?____________________________ __________________________________________________________________________________________________
Are you being treated with prescribed narcotics? (Applicants on prescribed narcotics will need to complete the
regimen prior to admission or switch to non-narcotic pain medications.)
If Yes, what medications?_____________________________________________________________________________
Non- Psychiatric Medications:
List all current non-psychiatric medications:

Special Needs:
Do you have any type of disability?
Do you have any other type of special needs? *Special dietary needs are typically unable to be accommodated. Please speak to your admissions rep to discuss your needs.
MENTAL HEALTH

Have you ever been treated for mental disorders?
Have you ever been treated by a psychiatrist/psychologist?

Mental Health History: (Check all that apply to your current and past conditions)

Have you thought about, or attempted suicide in the past 3 months?
Name of Primary Psychiatrist/Psychologist:
Address: _____________________________________________ City: Dates of Treatment: ____/____/____ to ____/____/____ Reason for Treatment:
Mental Health Medications Currently Taking:
Medication Name

FINANCIAL INFORMATION (to be used to help determine eligibility for financial assistance)

Are you presently employed?
No If yes, what is your monthly income? ____________ Do you receive any other income (SSI, disability, etc)?
No If yes, what is the monthly amount? ________ Do you currently receive any government assistance?
No What type? ___________________________ Do you have medical insurance?
No If yes, please provide the following information: Insurance Provider:________________________________ Member ID Number:______________________ City:___________________ State:________ Zip:_________ Phone: ( )____-______
Do you have a case worker:
No If yes, please provide the following information: LEGAL ISSUES

Are you currently on probation?
Are you currently on parole?
Do you currently have any court cases pending?
Are you currently under investigation for anything?
Do you currently have any outstanding warrants?
Have you ever been convicted of a violent crime?
No If yes, please list each conviction and date: _______________________________________________________________________________________________ Have you ever been convicted of a sex related crime:
No If yes, please list each conviction and date: _______________________________________________________________________________________________ Are you currently facing charges for a violent or sex related crime?
_______________________________________________________________________________________________ Are you required to register as a sexual or predatory offender?
Probation Officer’s Name:
Attorney’s Name:
EMERGENCY CONTACTS

Primary Contact Name: _________________________________ Relationship: ______________________________
Address: ______________________________________ City: __________________ State: ______ Zip: __________
Home Phone: _______________________ Alternate Phone: ___________________ Email: _____________________
Secondary Contact Name: __________________________________ Relationship: ___________________________
Address: ______________________________________ City: __________________ State: ______ Zip: __________
Home Phone: _______________________ Alternate Phone: ___________________ Email: _____________________
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APPLICANT’S STATEMENT

By my signature below, I certify that all answers and statements on this application are true and complete to the
best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers, I
may be discharged from the MnTC program. Furthermore, I understand that MnTC is a Christian, faith-based
program and that I have made a free and independent choice to enroll. I understand that other program options
are available to me and I have had an opportunity to request a referral.
I agree that that I will settle any and all previously unasserted claims, disputes or controversies arising out of or
relating to my application, participation in and discharge from the MnTC program with MnTC by final and binding
arbitration in accordance with the applicable American Arbitration Association rules of arbitration in effect on the
date that arbitration is requested by either me or MnTC. I agree that all administrative costs of arbitration shall
be divided equally among the parties.
_____ Program Policies and General Information Twelve Steps to Recovery and
Voluntary Participation in Faith Based Activities
All traditional 12-Step treatment programs recognize the importance of spirituality as it relates to sobriety and recovery. The Minnesota Department of Human Services licenses various models of treatment, many in which faith plays a very active role. The MnTC program focuses on the Christian faith in the 12 steps of recovery. Step 1 – Admit we are powerless over our addiction – that our lives have become unmanageable.
Step 2 – Come to believe that a Power greater than ourselves could restore us to sanity.
Step 3 – Make a decision to turn our will and our lives over to the care of God as we understand God.
Step 4 – Make a searching and fearless moral inventory of yourself.
Step 5 – Admit to God, to ourselves and to another human being the exact nature of our wrongs.
Step 6 – Are entirely ready to have God remove all these defects of character.
Step 7 – Humbly ask God to remove our shortcomings.
Step 8 – Make a list of all persons we have harmed, and become willing to make amends to them all.
Step 9 – Make direct amends to such people wherever possible, except when to do so would injure them or others.
Step 10 – Continue to take personal inventory and when we are wrong promptly admit it.
Step 11 – Seek through prayer and meditation to improve our conscious contact with God as we understand God, praying
only for knowledge of God’s will for us and the power to carry it out. Step 12 – Having had a spiritual awakening as a result of these steps, we try to carry this message to other addicts, and to
practice these principles in all our affairs. No provider of substance abuse services receiving federal funds from the U.S. Substance Abuse and Mental Health Services Administration may discriminate on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to actively participate in religious practices. While involved with MnTC, if you choose to decline to participate in a particular religious activity please notify a program staff and an alternative activity will be provided for you. If at any point you object to the religious components of the program, please notify your counselor and/or program director and we will work with you to find a program that will better meet your needs. _______________________________________________________________________________________________________________________________________ My signature below indicates that I have carefully considered the faith component of the program and have made an informed, free and independent choice to participate in the MnTC program. I also acknowledge that I have been provided with a referral list of other programs (both religious and secular) in the event that I object to the religious nature of the program and its activities. I have further been informed that I may ask for a copy of this list at anytime during the program. (THIS PAGE MUST BE RETURNED WITH THE APPLICATION)
Authorization for Release of Confidential Information
Applicant’s Full Legal Name: _______________________________________________ Birth Date: _____/_____/_____ I authorize the disclosure of records and information about me between: Minnesota Teen Challenge “At the request of the individual,” I authorize the release of the following information: I understand that: 1. My health information is protected by Federal Confidentiality Rules (42 CFR Part 2; and/or HIPAA, 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances as outlined in MTC policies. I understand that I have the right to inspect and receive a copy of my treatment records that may be disclosed to others, as provided under applicable state and federal laws. 2. I can revoke this authorization in writing at any time by providing a written notification to MTC, except to the extent that action has been taken in reliance on it. This authorization will expire one year from the date I sign, unless I request an earlier revocation in writing. 3. For disclosures other than treatment, payment, and healthcare operations purposes, treatment may not be conditioned on my agreement to sign an authorization, unless I am receiving care solely to create protected health information for disclosure to a third party. 4. Communications resulting from this authorization will reveal that I have received services at Minnesota Teen Challenge. 5. Federal confidentiality regulations prohibit re-disclosure of information. Applicant Signature
Staff Signature
(THIS PAGE MUST BE RETURNED WITH THE APPLICATION IF YOU WANT US TO
TALK TO SOMEBODY ELSE ABOUT YOUR ENROLLMENT IN THE PROGRAM)
Program Policies & General Information
The Minnesota Teen Challenge (MnTC) program is a licensed residential treatment program with a faith component. The
program assists individuals in recovering from drug and alcohol abuse and the life-controlling problems associated with it.
MnTC does not discriminate on the basis of race, color, creed, religion, sex, national and ethnic origin, marital status,
public assistance, sexual orientation, family status, or disability in the administration of its educational, admission, or
program policies or procedures.
Each resident will have access to our “Student Manual” which covers the policies of the program. MnTC reserves the
right to make changes in policy whenever necessary. When a change in policy occurs, residents and staff will be notified
and the “Student Manual” will be updated to reflect the change. Highlighted below are some basic
requirements/guidelines all MnTC residents are expected to adhere to while in the program. This is not a complete list,
but will serve as a basic example of what will be expected:
Appearance & Dress Code

Personal hygiene must be maintained in a neat and clean manner.
 Dress requirements for residents include three main dress codes: Casual/Class dress:
Males- collared shirts (no t-shirts), casual slacks, dress jeans or shorts.
Females- shirts, blouses, casual slacks, skirts, dresses, dress jeans or shorts (tank tops may only be worn with
a shirt over it.)
MnTC graduation and special events:
Males- black dress trousers, white long sleeve button down collared shirt, dark colored shoes and socks.
Females- black skirt (must come to below the knee), white long sleeve collared blouse, white camisole, black
or flesh colored nylons, and black shoes.
Leisure/recreational dress:
Shorts (must cover ¾ of thigh), t-shirts, sweat suits, bathing suit and jeans.
 Residents may not wear jewelry in any body piercing, with the exception of ears for female residents only.  Hairstyles and colors that bring unusual attention are not allowed.
Approved Personal Belongings

The following is a list of items residents should bring if they have them. If they don’t have them and don’t have the
means to purchase them, many of them may be provided at no cost.
Please note due to space limitations residents may only bring two plastic garbage bags worth of belongings.
 Clothing: See dress code above. Winter/rain/light jacket, gloves, underwear, socks etc.  Toiletries: soap, comb, toothbrush/paste, shampoo, deodorant, razor/shaving cream, blow dryer. Females:  Medications: 30 day supply of all prescription medications (prohibited medications), non-prescription medications. Must be in original container.  Misc.: Books(subject to approval), envelopes/stamps, umbrella, personal items, single serving non-perishable snacks, nicotine patches (NO GUM), water bottle. Prohibited Personal Belongings
Storage space for personal items is limited Due to this residents will only be allowed to bring (2) disposable plastic bags
worth of belongings. Suitcases are not allowed for health reasons. In addition to the two bags limit residents may not
bring any of the following items. If they do, they will be required to immediately dispose of them or mail them home at
their own expense.
 Expensive jewelry/clothing or other valuable items  Electronics: DVD players/DVD’s, headsets, video  Tools of any kind games, radios, TV’s, CD players/CD’s, mp3 players,  Weapons of any kind computers, cell phones, cameras.  Drugs or drug paraphernalia, alcohol & tobacco  Women/girls: Any kind of razor with a blade (includes
any make-up sharpener, electric razors allowed)
Employment/Living Standards

Due to the nature and schedule of our program, residents are not able to seek employment or be employed throughout the
duration of their treatment.
 All residents will be required to participate in general housekeeping and clean-up assignments. Mail/Visitation/Phone Time

The first week of the program is considered the orientation period. During this time, mail, phone, and visitation
communication is limited.
 Residents may receive preapproved visits from their personal physician, religious advisor, county case manager,  After the orientation period, correspondence will be limited to those who have been approved i.e. those individuals who will contribute to the resident’s recovery. Mail from those who have not been approved will be returned to the sender.  Residents are allowed two 10 minute phone calls per week, to people who have been approved. Medical/Dental Care & Prescription Medications

Residents are responsible for all their health care expenses. Residents who do not have medical and/or dental insurance
will be provided help in signing up for Minnesota Health Care and General Assistance. Since this is a county/state
program MnTC cannot guarantee that any resident will be approved for medical and/or dental benefits.
 Residents are required to obtain a summary of each medical and dental visit prior to leaving the place of treatment and must provide the information to their staff immediately upon return to MnTC.  Residents should bring enough prescription medication to last at least 30 days, and bring it in their original  Residents are strongly encouraged to take prescription medication exactly the way their doctor prescribes it. If subsequent medical treatment or behavioral issues arise as a result of a refusal to take prescribed medications, the resident may be discharged from the program.  While in MnTC residents are not permitted to take narcotics and certain other medications. Please see the Prohibited Medications document in this packet. Possession/Use of Drugs, Alcohol & Tobacco

Possession and/or use of drugs, alcohol and tobacco are prohibited while enrolled in our program.
 For the safety of all participants, residents may be subject to drug and/or alcohol tests at any time without prior notice. Residents who test positive for drugs and/or alcohol use while in our program may be discharged from MnTC. In addition, residents their rooms, and their personal property may be searched at any time without prior notice or approval to ensure the safety of our environment. Daily Schedule

Residents participate in all daily scheduled programming and activities, with the exception of optional recreational
activities. Residents can expect a typical weekday at MnTC to include the following: chapel, classes, counseling, groups,
and individual study time.
 Saturday’s are less structured and include time in the afternoon for visits from approved family and friends. Monday evening also allots time for visitation in the evening. No more than 7 visitors can attend at one time.  All gifts and packages are subject to inspection by staff for items we cannot allow. Passes
Residents of the Short Term Licensed Program are not allowed on passes except in the case of situations or events that promote treatment goals, i.e. visits to sober or half-way houses as part of after-care planning or emergency situations. Emergencies require special and immediate consideration. Upon verification of a qualifying emergency, the Primary Counselor will contact the referral and Probation or Parole Officer, if one is assigned to that resident, to authorize an Emergency Pass. If so, the Primary Counselor shall complete the “Student Emergency Pass” form and ensure the resident is aware of the date and time the pass expires. The amount of time allowed for the emergency pass will depend on the nature and location of the emergency, and the Probation or Parole Officer assigned to that resident. Qualifying Emergencies: Emergencies that qualify for approval of an emergency pass include the death, severe injury,
or severe illness of a close family member, or circumstances that threaten their immediate safety.
Abuse of Pass Privileges: Residents returning from pass will be checked/tested for drugs and or alcohol to insure
prohibited items are not brought into our facility.
Transportation: Residents are responsible for their own transportation to and from our facility when going on pass.
Program Fee Information__
The majority of the residents in MnTC are eligible to have some or all of the program costs paid for by their county. To determine eligibility and apply for funding, applicants must contact their county social services agency and request a Rule 25 assessment prior to admission. If an applicant is determined to be ineligible for funding, fees must be paid for out of pocket. In the event that a resident leaves the program prior to completion, fees will be pro-rated so that residents are charged only for the days they are enrolled in the program. Residents are considered enrolled in the program even though they may be temporarily away from our facility due to emergency. Residents will be charged for the day they are admitted into the program but will not be charged for the day they are discharged. Residents are required to pay for the first 30 days of the program at the time of admission. The next payment is due on the 31st day of the program. PLEASE READ below if you will be receiving a
RULE 25 ASSESSMENT
 You have the right to request placement with a provider that will honor o “The placing authority must authorize chemical dependency treatment services that are appropriate to the client’s…religious preference…The placing authority maintains the responsibility and right to choose the specific provider” (Section 9530.6620, Sub point 9).  You have the right to request a specific provider, such as Minnesota o “The placing authority must consider a client’s request for a specific provider. If the placing authority does not place the client according to the client’s request, the placing authority must provide written documentation that explains the reason for the deviation from the client’s request…” (Section 9530.6620. Sub point 14).  You have the right to appeal if you do not receive appropriate o “A client has the right to a fair hearing under Minnesota Statues…if the client…(F) is denied a placement that is appropriate to the client’s race, color, creed, disability, national origin, religious preference, marital status, sexual orientation, or sex” (Section 9530.6655, Sub point 2). For further information, please see the Rule 25 Chemical Dependency Assessment and Placement Rules and Laws: July 1, 2008 Prohibited Medications

Due to their interference with the recovery process, Minnesota Teen Challenge prohibits the use of all addictive
medications and those medications that have the potential for abuse and dependence. Prospective residents that are
currently taking any of the listed medications need to check with their health care provider, prior to or soon after
admission, to determine if an appropriate alternate medication is available. Prospective residents are strongly
encouraged NOT to discontinue use of medication without first checking with the prescribing doctor or if admitted to
MnTC, talking with the onsite nurse. Certain prohibited medications, such as the benzodiazepines (Klonopin,
Ativan, Xanax, Valium), also Campral, and medication used to treat opiate addiction (suboxone, methadone,
subutex) require a gradual tapering off the medication rather than stopping it abruptly. In this case, the tapering
must be done under the supervision of a physician. The tapering can be done while you are in the program.
In the rare circumstance that an alternate is not available, Minnesota Teen Challenge is not an appropriate treatment
option and a referral list of other treatment programs in the area will be provided.
Examples of addictive medications include but are not limited to the following:
All Narcotic pain relievers and pain relievers with potential for dependence and abuse
Vicodin-(hydrocodone with acetaminophen)
Tylenol with Codeine (acetaminophen with codeine)
*Due to the highly addictive nature of narcotic pain relievers and their potential to undermine the program
participants’ recovery efforts and mindset, prescriptions written for these medications, following a surgery or
injury, are not permitted while in MnTC. MnTC nursing staff will work with residents and their health care
providers to find other non-narcotic pain relievers that are permitted examples include ibuprofen and naproxen.
All medications used for the treatment of opiate dependence, e.g. Methadone, Suboxone, Subutex, Naltrexone
All barbiturates, including those combined with acetaminophen, caffeine or aspirin e.g. Fiorocet, Fiorinal
All Benzodiazepines
Xanax

Sleep Aids Ambien and Ambien CR (zolpidem), Sonata (zalepon)

Muscle Relaxants SOMA (carisoprodol)
All stimulant medications used to treat Attention Deficit Disorder & Attention Deficit/Hyperactivity Disorder
Adderall (amphetamine mixed salts)
Vyvanse (lisdexamfetamine)
* Strattera is permitted.

Any prescribed or over the counter medications used specifically for weight loss.

Smoking Cessation medication – Chantix (vareniclin)
*Only nicotine patches are allowed.

Source: http://aaimntc.whiskey.aaidev.net/sites/aaimntc.whiskey.aaidev.net/files/program-docs/Short%20Term%20Adult%20Application.pdf