APFN AGREEMENT

The confidentiality of recovering persons living in A Place For Now is protected under Federal Law 42 CFR, which protects them from anyone outside of the residence having knowledge of their participation in the recovery residence without the guest’s specific permission. No information regarding a guest of A Place For Now may be released to anyone outside of the program unless: The guest has signed a consent form to that person/agency; A court order is issued to A Place For Now regarding information on the resident Medical personnel require the information in a medical emergency, or the guest threatens to harm him/herself or someone else. Federal Law does not protect a guest if they commit a crime against anyone at A Place For Now. Also, Federal Law does not restrict sharing of information regarding reported child abuse/neglect to appropriate State and local authorities. These laws apply not only to the house manager/owner, member and volunteers of A Place For Now, but to the guests as well. I agree to not reveal to anyone outside of the A Place For Now the name, identity, or description of another guest. I also agree to not discuss the content of conversations or groups with anyone outside of A Place For Now. This includes sharing at 12-Step meetings. I agree to inform the house manager/owner if any of my peers reveal any information about themselves or another guest that may be a cause for concern. AUTHORIZATION FOR RELEASE OF INFORMATION I hereby request and authorize A Place For Now. To disclose or obtain from: Probation/Parole, Treatment Providers, Parents, Police, Hospitals, Labs, the following type(s) of information from my records (and any specific portion thereof):  History and Physical,  Alcohol and Drug Abuse Treatment records,  Laboratory Reports, Psychological Reports, All information I hereby authorize to be obtained from this agency will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that this authorization will remain in effect for: Ninety (90) days unless I specify an earlier expiration date here:       X       one (1) year or the period necessary to complete all transactions on account related to services provided to me. I understand that unless otherwise limited by state or federal regulation, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time. I understand that the common areas in and around the house may be video an/or audio monitored for the safety of the residents and property. Bedrooms and bathrooms will not be monitored in any way, shape or form.  CODE OF ETHICS Ac Place For Now strives to maintain a respectful environment built on honesty and trust. Focusing on our resident’s individual growth to include these core principles is important to us. A Place For Now guests will conduct our business honestly and ethically.  Will treat all persons with dignity and respect Will safeguard persons privacy and confidentiality per state, federal and local requirements Will not threaten or commit any act of physical or emotional abuse Will not become romantically or sexually involved with persons currently served (or served in the recent past) Will not engage in harassment Will not discriminate due to race, religion, age, sexual orientation, disability, national ancestry or economic condition (Does have latitude to outline specialty population served) Will strive for continued personal growth and self-improvement through education, training and consultations. RESIDENT RIGHTS AND RESPONSIBILITIES  POLICY - To safeguard the rights of persons who are guests at A Place For Now. BASIS - Each guest has certain rights and responsibilities to ensure the best experience possible. PROCEDURE A. Guests will be informed of their rights and responsibilities upon admission into the program and given a copy of the (Program Description) and House Rules. B. Resident Rights As a resident of Acceptance House you have the right to  Be treated with dignity and respect. Participate actively in your recovery. Be given information regarding informed consent prior to the start of your stay. Be seen by a private physician with the understanding that all costs will be the responsibility of the resident. Have all information pertaining to stay held in confidence. Receive information regarding cost. Be fully informed at the time of admission of the rights and responsibilities set forth herein and of all the rules and guidelines governing resident conduct.  Initiate a complaint or grievance procedure and understand that you may begin the grievance procedure by contacting the House Manager or House Owner(s). Request referral resources in the event of your dismissal from Acceptance House. Not to be required to perform services for Acceptance House, which are not included in the usual expectations of all residents. GRIEVANCE PROCEDURE  POLICY - Guests and house manager/owner members have the right to file a grievance against a recovery residence/NARR member. BASIS - Guests and recovery residence/NARR members have the right to a recovery residence environment without fear of speaking out about their rights. Every recovery guest/NARR member must provide all residents with a grievance form, along with written instructions on how to fill the form out, and where to send it. A grievance must relate to the organization’s mission statement, house rules, admission criteria, or the coalition/NARR bylaws. PROCEDURE When a guest has an issue, they must first take it up with the house manager, owner or owners of the organization for resolution. If a mutually agreeable resolution is not reached then a resident may file a written grievance with the coalition/NARR. The grievance must be specific in nature with all documentation attached. Upon receiving a grievance, the Coalition/NARR will notify the Board. The President shall determine whether to call a special coalition meeting or wait until the next regular scheduled meeting. If a special meeting is called, the Coalition President shall notify the Coalition members, contact person of the organization and the petitioner by mail of the date, time, and location of a meeting. Failure to appear for the meeting will be cause for dismissal, or expulsion from the coalition. The petitioner shall have an opportunity to present the issue at hand, and must have proof. A representative of the organization will have an opportunity to offer the reasoning behind the action taken. After hearing the facts behind the issue at hand the coalition will discuss in private to consider the merit of the grievance and may offer suggestions to the parties. The only action the coalition can take is to either dismiss the complaint for lack of merit or prove there is enough to deem a right to remedy provision or expel the organization from the coalition.  WHAT TO DO IN CASE OF AN EMERGENCY  Call 911 in case of:  Fire Violence or a threat of violence Suspicious persons hanging around premises Burglary A life-threatening medical situation Chest pain Shortness of breath Suicide attempt Unconscious individual Injury in which there is a broken bone or bleeding that cannot be stopped  Serious fall Unable to wake someone Ingestion of toxic chemicals or substances. Individual out of control Individual having hallucinations Individual having an extreme allergic reaction Extreme paranoid behavior  After you call 911, call the house manager/owner and inform them of the situation.Then move to a safe place to wait for the arrival of emergency assistance.DO NOT try to move an injured person, give First Aid or CPR unless you are qualified.  Call the house manager/owner in case of:  Drugs, alcohol, weapons on the premises Suspicion or knowledge of someone using/having used drugs/alcohol Plumbing problems or maintenance issues in the house Power out for more than a half an hour  Individual who may be in withdrawal having difficulties Curfew violations RESIDENTS ON PROBATION OR PAROLE  POLICY - A Place For Now will be in communication with guests’ probation or parole officers. BASIS - It is vital that probation and/ or parole officers receive timely information on their clients who are guests of A Place For Now.  PROCEDURE  Guests who are on probation or parole must sign the A Place For Now authorization for release of information form to allow the release of information on their status at A Place For Now to their probation or parole officer. Guests’ probation or parole officers will be notified by phone immediately or by the start of the next day of any positive drug screen results, serious rule violations and associated sanctions, arrests or law violations known by the A Palce For Now manager/owner. A guests’ probation or parole officer will be notified by phone prior to discharge from A Place For Now. A guests’ probation or parole officer will be notified by phone if the guest does not self- administer any medication as prescribed.  MEDICATIONS  POLICY - Guests may take certain medications under the supervision of a qualified physician. BASIS - A percentage of the guests who come to A Place For Now are on some type of medication either for a physical or psychiatric concern.  PROCEDURE Guests may not take any mood-altering medications (e.g. opiate-based pain medications, benzodiazepines, barbiturates, sedatives-hypnotics, sleeping pills, diet pills) In rare instances, a patient may have a medical procedure or pain that requires brief use of medicines that are not on the guests‘ safe drug list’. Guests at that time must submit to the house manager/owner of A Place For Now physician documentation of the necessity of the medication. Only the house owner can authorize use of any medication at A Place For Now that is not on the safe drug list. Medications will be stored in a locked box. Guests must inform the house manager/owner of any prescriptions/medications they have when they are admitted to Acceptance House and any prescriptions/medications they receive while a guest of A Place For Now. Failure to do so will result in disciplinary action and possible discharge. Guests may only take over the counter medications that are approved by A Place For Now on the ‘safe drug list’. Guests who are on any medication must be able to self-administer their own medication without the aid of a health-care professional. If a resident is unable to do so, then they will be referred to a facility that can aid them. Guests who are on medication are responsible for the proper dosage of their medication. Medication must be stored, not accessible on counter tops or dressers. The preferred storage for any medication is a lock-box, which the house manager/owner has a key to. Any deviation from the proper medication dosage will be investigated by the house manager/owner. Deliberate alteration of the dosage in an attempt to alter mood will result in disciplinary action and possible discharge. Guests must not discontinue taking any prescribed medications without the written authorization of a medical doctor.  REVOCABLE LICENSE  This Transition Program with A Place for Now is a temporary revocable license to occupy the provided facility and is not a lease but rather provided service(s).  The Transition Program will provide services to support those who have been through a recovery program and are ready to prepare to find a place to live permanently and obtain employment.  While in the program services may or may not include job training, transportation, educational resources, and shared spaces for living such as a kitchen, living, and bath.  Any available services will not be given any exclusive right to any participant such as premises and services and other participants may not be excluded from the same rights as all participants.  By accepting the services of this agreement, all participants must agree and acknowledge and adhere to the Transition Program guidelines and Rules (to be outlined in this agreement).