FREEDOM RECOVERY IOP REGISTRATION

FREEDOM RECOVERY'S INTENSIVE OUTPATIENT PROGRAM REGISTRATION FORMS
Welcome to Astra Behavioral Health's Adult Virtual Intensive Outpatient Program!

As a participant in Astra Behavioral Health's Freedom Recovery program, you will be able to learn strategies to better manage recovery from chemical dependency, and mental health difficulties, that often make day-to-day life incredibly challenging. Astra Behavioral Health's Freedom Recovery Adult Virtual IOP accepts ages eighteen (18) years of age and older. We do not accept adolescents, anyone seventeen (17) years of age and under, into our adult program. If you are a parent or guardian requesting Adolescent IOP services for your child under the age of eighteen (18), please reach out to our recovery team at recovery@astrabh.com or call us at (270) 900-4588 for information regarding Adolescent IOP programs.

In our IOP program, we focus on treating Dual-Diagnosis, meaning both the chemical dependency, and other mental illnesses. We believe addiction and alcoholism runs hand-in-hand with underlying mental illnesses. To best treat the chemical dependency, we must treat the mind as a whole. The Freedom Recovery program offers two virtual adult group times to best fit into your work, school and family schedules. We hope to break down any barriers that may hinder you from receiving treatment.
- Daytime Group: 10:00am - 1:00pm EST
- Evening Group: 5:00pm - 8:00pm EST
IOP Group Session Days: Monday, Wednesday and Thursday

Freedom Recovery utilizes a team approach to provide you with an encompassing treatment plan personalized to your recovery goals. Your recovery treatment team could consist of the following:
- Therapist: works with participants in group, individual, and family counseling.
- Psychiatrist/Nurse Practitioner: works with participants to monitor and manage any psychiatric medications deemed appropriate.
- Primary Care Physician: will be informed of your participation via letter and encouraged to communicate as part of the treatment team as appropriate.
- Patient Care Coordinator: guides you through our program and will be your main point of contact for additional support in your recovery.
- Targeted Case Management: if eligible, this service is highly recommended to assist you in obtaining needed resources and goal-setting.
- You: as the most essential part of your treatment, you will need to put effort into your treatment and implement new strategies into your life.
We proudly accept most Commercial and Medicaid insurance plans in our Freedom Recovery program. Just a few insurance providers we accept include: Anthem BCBS, Humana, Cigna, Aetna, United Healthcare, Passport, Wellcare and many more! If you do not see your insurance provider's name on this list, please give us a call at (270) 900-4588 to verify coverage.

DATE OF BIRTH*

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Date
TODAYS DATE*

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FREEDOM RECOVERY CLIENT SERVICE AGREEMENT

Please review the following as it is important that you understand the kinds of services you will be provided and the Terms and Conditions under which these services will be offered.
I, First Name* Last Name* am requesting treatment from the staff of Astra Behavioral Health. As a condition of that treatment, I acknowledge the following terms, and agree to them.
I UNDERSTAND AND AGREE TO THE FOLLOWING:
INITALS1. The staff believe the outpatient treatment model, the Matrix Model, used within the program provides a useful intervention for dual-diagnosis treatment; however, no specific outcome can be guaranteed.
INITALS2. Treatment participation requires some basic ground rules. The rules and conditions of our program are written within the following pages of this agreement. These rules and conditions are essential for a successful treatment experience. Violation of these rules can result in treatment termination.
INITALS3. Confidentiality: All information disclosed in these sessions is strictly confidential and may not be revealed to anyone outside the program staff without the written permission of the client or the client’s family. The only expectations are when disclosures are required or permitted by law. Those situations typically involve substantial risk of physical harm to self or other or suspected abuse of children or the elderly.
INITALS 4. Completing the program: Graduation of the Freedom Recovery program requires your cooperation and active participation while enrolled in the program. Lack of cooperation may interfere substantially with the program’s ability to render services effectively to yourself or to others. Under such circumstances, the program may discontinue your enrollment in the program without graduation.

After completing our 32-session program, you will receive a signed Certificate of Completion to utilize however you may choose. If you are on probation or under legal obligation to complete a drug and alcohol treatment program, you may need to submit this Certificate to the required parties as proof of completion.

CLIENT NAME

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
TODAYS DATE

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INITALSa. It is necessary to be on time for group sessions and individual therapy appointments. Should you need to use the restroom during group, please inform the group therapist before doing so
INITALSb. Conditions of treatment require abstinence from all drug and alcohol use for the entire duration of the treatment program. If I am unable to make this commitment, I will discuss other options with staff members involved in my treatment.
INITALSc. I will discuss any and all drug or alcohol use with staff members involved in my treatment and during group sessions while in treatment.
INITALSd. I understand that I am required to attend ALL three group sessions each week, while enrolled in the Freedom Recovery program. I also understand that if I have three (3) unexcused absences within the 32-session duration, I will be required to have a treatment meeting with recovery staff members before returning to the following group session and may be removed from the program. I understand that group appointments cannot be rescheduled and attendance is extremely important. I will notify my counselor or Patient Care Coordinator in advance if I am going to miss a group session.
INITALSe. I understand that excused absences consist of, but are not limited to: Court appointments, doctor appointments, severe illness, family emergencies, parole officer meetings, or other legal obligations. All excused absences require prior approval from a member o f the recovery treatment team at least 1 week in advance.
INITALSf. I understand that unexcused absences consist of, but are no limited to: no-call-no-shows, running errands, forgetfulness, minor sicknesses, homework, hanging out with friends or driving. If I am running behind or will be tardy to a group session, I will notify recovery staff as soon as possible. Tardiness over 1 hour will be considered “incomplete” and will not be counted as one of the 32 sessions.
INITALSg. I understand my enrollment in the Freedom Recovery program will be terminated if I attempt to sell drugs or encourage drug use by other clients.
INITALSh. I agree not to become involved romantically, sexually or become involved in business transactions with other clients.
INITALSi. I understand that graphic stories or “war stories” of drug or alcohol use will not be allowed.

CLIENT NAME

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
INITALSj. I understand that all matters discussed in group session and the identity of all group members are absolutely confidential. This includes, talking about what is shared in the group outside of group and not talking about other group member's experiences. I will not share this information with nonmembers.
INITALSk. During group session, I will remain visible to my therapist and in front of my video camera. I understand that participation is required to be in this program and to participate I must be visible. I understand that I can turn off my video camera during break periods, or restroom breaks.
INITALSl. Respect for others is expected from all participants. This includes allowing other to express themselves in session, listening to others without giving unprompted advice, speaking for yourself and not others, and maintaining appropriate boundaries.
INITALSm. All treatment is voluntary. If I decide to terminate treatment, I will discuss the decision with the Patient Care Coordinator or Therapist before leaving the program.
INITALSn. I understand that I may be recommended to a higher level of care if I am having suicidal and homicidal thoughts/feelings.
INITALSo. I understand that I may be required to complete random Urine Drug Screen(s) (UDS) at the request of the staff involvement in my treatment during my time in this program.
CLIENT SERVICE AGREEMENT AND CONSENT
I certify that I have read, understand, and accept the Client Service Agreement and Consent. This agreement and consent covers the full length of time in which I am involved in treatment services through Astra Behavioral Health, LLC.
CLIENT SIGNATURE*

Clear
TODAYS DATE*

MonthDayYear
Date
WITNESS SIGNATURE

Clear
TODAYS DATE

MonthDayYear
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FREEDOM RECOVERY'S INTENSIVE OUTPATIENT PROGRAM REGISTRATION FORMS

FREEDOM RECOVERY CLIENT SERVICE AGREEMENT

I, First Name* Last Name* am requesting treatment from the staff of Astra Behavioral Health. As a condition of that treatment, I acknowledge the following terms, and agree to them.

CLIENT SERVICE AGREEMENT AND CONSENT

PHYSICAL HEALTH STATUS QUESTIONNAIRE