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Record Keeping
Each client’s records are kept in their personal and confidential three-ring binder, which is stored under lock and key. The information contained in this binder is organized under the following tabbed sections: Intake, Medical, Mentoring, Confidential, Staff Notes, Drug Screens and Misc. The documents contained in the Clients Chart/Binder are:
- Screening Information
- Resident’s Agreement to Comply with Program Guidelines
- Admission Agreement
- Informed Consent to Receive Recovery Services
- Record of Drug Use History
- Medical Admit Note
- Addiction Severity Index
- Drug Test Results
- Personal Safety Plan
- Authorization For Release of Information
- Confidentiality of Client Records Statement
- Client’s Rights to Privacy Statement
- Visitation Guidelines
- Emergency Plan
- Mentoring Plan & Progress Report
- Stages of Mentoring Development
- Letter of Financial Agreement
- Record of Client’s Payment of Fees