Akeela House Recovery Center

INTAKE PACKET
MEMORANDUM – Intake Introduction
TO: All Referral Professionals

FROM: Intake Coordinator

Akeela House Recovery Center
Phone: (907) 561-5266
Fax: (907) 562-5041

Thank you for your interest in the Akeela House Recovery Center, part of Akeela, Inc.

A completed packet is to include all documents listed on the INTAKE CHECKLIST.

Please fax completed packets to Akeela House Intake Coordinator at number above.

There are more applications than available beds for treatment. A wait list is maintained
for applicants who are approved for admission until beds are available. (See below for
information on priority admission criteria.)

Akeela House Recovery Center admission policies include Priority Admission Criteria.
Applicants who meet any of the Priority Admission Criteria will have priority over other
individuals on the Wait List (per State of Alaska Wait List Protocol). Please see Intake
Form for the complete list of criteria.

It is long-standing policy for Akeela treatment programs that persons with criminal
charges that have not yet been adjudicated (pre-sentence) are ineligible for admission.

Please inform the applicant that submitting the application package does not mean
acceptance into the Akeela House treatment program. After submitting a completed
packet, an interview with the Intake Coordinator may be required, the interview may be
either in person or by telephone. The admission process includes treatment team
review of completed intake packets.

Also please inform the applicant that after submitting a completed Intake packet, the
applicant will need to have contact with the Intake Coordinator. If the applicant does not
have a phone or a reliable contact phone number, the applicant will take the initiative to
contact the Intake Coordinator at Akeela House on a regular basis. If you require
further information, please contact the Intake Coordinator at numbers above.

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 Akeela House Recovery Center

INTAKE CHECKLIST
A completed intake packet is to include the following 5 items:

1) Intake Form (Page 3 - 4)

2) Medical, TB, Medication Self-Administration Form (Page 5 - 7)

This form has to be filled out by a Health Care Provider. Completed within
past 30 days. (Upon approval, you may be placed on a waitlist. You are
required to provide TB clearance within 30 days before admission.)

3) Behavioral Health Assessment

(Contact (907)433-7080 to schedule an assessment date and time.
Assessment has to be completed within past six months. Comprehensive
Biopsychosocial Substance Abuse and Mental Health evaluation to
include DSM--5 and ASAM-3rd edition diagnoses with treatment
recommendations requiring level 3.3-3.5 level of care — must be
completed within the past 6 months

4) Releases of Information (ROI) {Page 8 (sample) – Page 9 (blank form)}

Include a separate signed ROI for each of the parties involved in the
applicant’s case, i.e., physician, attorney, parole officer, counselor, OCS,
etc. A separate ROI is required for each person or agency.

5) If on probation or parole, copy of the Presentence Report

After all five boxes are checked above,

Fax all the above completed paperwork to Akeela House Intake at (907) 562-5041.
You may also scan and email your application to [email protected]
or mail to Akeela House Intake, 2804 Bering Street, Anchorage, AK 99503.

Thank you,
Intake Coordinator, Akeela House Recovery Center
Phone: (907) 561-5266
Fax: (907) 562-5041

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 Akeela House Recovery Center

INTAKE FORM
This form is to be completed by the referral agency and applicant together. Please be
as specific as possible as incomplete information will slow admission process.

Referring Individual Name: ___________________________________________

Referring Agency Name: ____________________________________________

Mailing Address: __________________________________________________

City: ________________________ State: ___________ Zip: ____________

Phone Number: _________________ Fax Number: _______________________

Will the client be returning to you after treatment? Yes No

If No, what counselor will provide follow-up care: ______________________________

Applicant Personal Information:

Name: ____________________________ Birth date: _____________ Age: ____

Mailing Address: __________________________________________________

City: ________________________ State: ___________ Zip: ____________

Can we leave a message at this phone?
Home Phone: __________________________ Yes No

Work Phone: ___________________________ Yes No

Other Contact Phone: ____________________ Yes No

Priority Admission Criteria: Check all that apply:

Pregnant Woman.
Injection Drug User (IV Drug User).
Imminent danger to self or others and repeated use of treatment resources, that
is, has continuous or multiple prior substance abuse treatment placements.
On DOC Furlough.
HIV/AIDS Positive.
Women with Children (with or without OCS custody or OCS supervision.)
Have co-occurring mental health and substance abuse disorder diagnoses.
Referrals from Alcohol Safety Action Program, or Therapeutic Courts, or API.

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 Akeela House Recovery Center

PLEASE REVIEW THE FOLLOWING GUIDELINES WITH THE APPLICANT:

 In order to be admitted into the program, you must be well enough to participate in
the program. If you arrive under the influence of alcohol or other drugs, or in
withdrawal requiring clinical intervention, you will be referred to an appropriate
detoxification setting before treatment.

 Akeela House is not responsible for your transportation or any other personal costs
you may incur (e.g., approved medications) while in treatment.

 Please bring required medications. Medications must be in the original prescription

bottle with the original prescribed information and may not be mixed in with other
medications.

 Clients who are indigent will be admitted for treatment to Akeela House grant funded
programs without regard to their ability to pay or not pay. Treatment fees will be
determined using a sliding fee scale appropriate to the client’s income and family
status utilizing the federal poverty guidelines.

I agree that the information provided by me in development of the Behavioral Health

assessment, history and physical, and other intake paperwork is true and accurate to
the best of my knowledge.

I have signed an enclosed Release of Information to obtain further information that is

necessary to determine my suitability for treatment and/or to confirm I will be reporting
for treatment at Akeela House Recovery Center as scheduled.

I have also signed a Release of Information, which authorizes my physician to release

to Akeela House Recovery Center, medical information which is required to assess my
suitability for acceptance and admittance into the residential treatment program.

Other Releases of Information may also be required from other agencies (DOC, Courts,
OCS, etc.) should also be signed for a comprehensive understanding of your
appropriateness for our program.

I have read and agree to the enclosed “Resident Information and Responsibilities.”

Applicant’s Signature____________________________ Date______________

Page 4
 Medical Clearance Form

PATIENT NAME: _____________________________ DATE OF BIRTH: _______________

PLEASE PRINT

The following medical information form must be completed by a health care provider
in order to participate in AKEELA Residential Treatment Program.

Does this patient require detoxification prior to entering treatment? □ NO □ YES

Does this patient have any physical impairments/limitations? □ NO □ YES

If YES, please explain:
_________________________________________________________________________
_________________________________________________________________________

Does this patient have any communicable diseases? □ NO □ YES

If YES, please explain:
_________________________________________________________________________
_________________________________________________________________________

If applicable, is this patient pregnant? □ NO □ YES - ______________________________

PHYSICAL EXAMINATION
SYSTEMS NORMAL ABNORMAL TB CLEARANCE
Abdomen
Skin Test:
Cardiovascular
Administered Date: _____________ This patient has been medically
Extremities
Read Date: ______________ evaluated and cleared to participate in
Genitals residential treatment which may include
Lungs ______mm Negative / Positive
Results: groups and other activities up to 8 or
Neck/Thyroid more hours per day. □ NO □ YES
Neurological
X- RAY: If NO, please explain:
Skin _________________________
Results:
Vital Signs
_________________________________________________________________________
_________________________________________________________________________

Is this patient in psychiatric crisis? □ NO □ YES

If YES, please explain:
_________________________________________________________________________
_________________________________________________________________________

Has this patient reported any recent suicidal ideation or homicidal ideation? □ NO □ YES
If YES, please explain:
_________________________________________________________________________
_________________________________________________________________________

Does this patient have a regular Primary Care Provider? □ NO □ YES

If YES, please list:

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_________________________________________________________________________

Does this patient have a regular Mental Health Provider? □ NO □ YES

If YES, please list:
_________________________________________________________________________

__________________________________ ____________________________
Signature of Physician / PA / ANP Date:

Name of Clinic: _________________________________

Medical Clearance for Self-Administration of Medication

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MEDICATION LIST FOR CLIENT
Name of Medication Prescribed By Dosage Route

If the patient is prescribed addictive or narcotic medications are there non-narcotic

alternatives? □ NO □ YES
If YES, please list: ____________________________________________________________

RE: Medical Clearance for Self-Administration of Medication

1. The person listed below is requesting substance use disorder treatment at a residential
treatment program of Akeela, Inc. The residential treatment program does not
administer medications, but instead safely stores medications so that clients can then
take their own medication (self-administration) as prescribed by their prescriber.
2. In keeping with regulations by the State of Alaska, persons entering residential
treatment in which clients take their own medication require a medical clearance from a
physician, PA or ANP that states the client is capable of self-administration of
medication prescribed.
3. If you have questions, please call specific Akeela House Program Manager at (907) 561-
5266. Or please call Akeela Chief Clinical Officer at 907-565-1200.

Name of Client: __________________________________________

DOB: __________________________________________________

The person named above is capable of self-administration of medication prescribed.

_____________________________________ __________________
Signature of Physician / PA / ANP Date:
Name of Clinic: _________________________________
Clinic Office Phone Number: ____________________________

SAMPLE - RELEASE OF INFORMATION

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I, ___JOHN DOE______________________ DOB__01/01/1988_____PHONE # :__( 907)555-5555__________hereby request/authorize
records:

FROM: Office of Children Services / OCS 1000 Bethel Road___Bethel _ AK_____________99559_____ be sent to:
Name of Person/Agency Address City State Zip Code

TO: Akeela House_ 2804 Bering St. Anchorage AK 99503_____

Name of Person/Agency Address City State Zip Code
How are records/information to be delivered: (initial all that apply)
JD FAX: ELECTRONIC (EMAIL)*: JD VERBAL JD MAIL JD I will pick- JD Exchange
(Number) up records Information
between parties

*Email is not considered to be as secure as other means of delivery and should be carefully considered prior to authorization.
The following specific information (For care received from ________________________to_______________________________)
Initial all that apply:
Admission Assessment Transfer/Discharge Summary Progress Notes
Treatment Plan/Updates JD Attendance Leave Message for client to contact
UA Results Client Presence in Treatment agency
JD Other(Please specify):
VISITS
The purpose of the release of this information is (Initial all that apply):
JD Sharing with other health care providers My personal records Legal
JD Coordination of Care Further Treatment
Other(Please specify):
I understand that the information in my health record may include information relating to acquired immunodeficiency syndrome (AIDS) or
human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and
drug abuse. Exchange of information ensures continuity of care between providers. By not sharing information, my health care could be
compromised.

I hereby authorize the use or disclosure of my health care and/or other information as described above. I understand that this authorization is
voluntary. I understand that the individuals(s) or organization releasing this information will not condition my treatment, payment, enrollment in
a health plan (If applicable) or eligibility for benefits on whether I provide this authorization. I understand that if the person(s) or organization
authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal
privacy regulations. To the extent that this information is required to remain confidential by federal or state law, the recipient of this information
must continue to keep this information confidential.

I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse
Patient Records, 42 CFR, Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR parts 160 and 164, and
cannot be disclosed with your written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent
in writing at any time except to the extent that action has been taken reliance on it and that in any event this consent expires automatically as
follows: (Date of expiration or Event triggering expiration)_____________________________________________________ (No more than 1
year from signature)

By my signature below I indicate that I have read this document, or have had it read to me, that I fully understand its meaning, that I have
consented to its terms knowingly and voluntarily, that I have not been under any undue duress or influence of alcohol or drugs in making this
agreement.

Jane Doe_____________________________________ 3/16/2016________________________________________

Signature of Client Date
____________________________________________ ________________________________________________
Signature of Parent, Guardian, or person authorized Date

RECIPIENT INFORMATION: If the information released pertains to alcohol or drug abuse, the confidentiality of the information is protected
by federal law (CFR 42 Part 2) prohibiting you from making any further disclosure of this information without the specific written authorization
of the person to whom it pertains or as otherwise permitted by CFR 42 Part 2. A general authorization for the release of medical or other
information if held by another party is not sufficient for this purpose. The federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient.
REVOCATION:
I, ____________________________ hereby revoke the above Release of information as of:____________________ (date).

____________________________________________ ________________________________________________
Signature of Client Date

____________________________________________ _______________________________________________
Signature of Parent, Guardian, or person authorized Date

AUTHORIZATION FOR RELEASE OF INFORMATION

Page 8
I, _____________________________________ DOB_____________ PHONE #:___________________hereby request/authorize records:

FROM: _______________________________ ___________________________________________________ be sent to/from:

Name of Person/Agency Address City State Zip Code

TO: _________________________________ ___________________________________________________

Name of Person/Agency Address City State Zip Code
How are records/information to be delivered: (initial all that apply)
FAX: (Number) ELECTRONIC (EMAIL)*: VERBAL MAIL I will pick-up Exchange
records Information between
parties

*Email is not considered to be as secure as other means of delivery and should be carefully considered prior to authorization.
The following specific information (For care received from ________________________to_______________________________)
Initial all that apply:
Admission Assessment Transfer/Discharge Summary Progress Notes
Treatment Plan/Updates Attendance Leave Message for client to contact
UA Results Client Presence in Treatment agency
Other(Please specify):

The purpose of the release of this information is (Initial all that apply):
Sharing with other health care providers My personal records Legal
Coordination of Care Further Treatment
Other(Please specify):
I understand that the information in my health record may include information relating to acquired immunodeficiency syndrome (AIDS) or
human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and
drug abuse. Exchange of information ensures continuity of care between providers. By not sharing information, my health care could be
compromised.

I hereby authorize the use or disclosure of my health care and/or other information as described above. I understand that this authorization is
voluntary. I understand that the individuals(s) or organization releasing this information will not condition my treatment, payment, enrollment in
a health plan (If applicable) or eligibility for benefits on whether I provide this authorization. I understand that if the person(s) or organization
authorized to receive this information is not a health plan or health care provider, the released information may no longer be protected by federal
privacy regulations. To the extent that this information is required to remain confidential by federal or state law, the recipient of this information
must continue to keep this information confidential.

I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse
Patient Records, 42 CFR, Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR parts 160 and 164, and
cannot be disclosed with your written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent
in writing at any time except to the extent that action has been taken reliance on it and that in any event this consent expires automatically as
follows: (Date of expiration or Event triggering expiration)_____________________________________________________ (No more than 1
year from signature)

By my signature below I indicate that I have read this document, or have had it read to me, that I fully understand its meaning, that I have
consented to its terms knowingly and voluntarily, that I have not been under any undue duress or influence of alcohol or drugs in making this
agreement.

____________________________________________ ________________________________________________
Signature of Client Date
____________________________________________ ________________________________________________
Signature of Parent, Guardian, or person authorized Date

RECIPIENT INFORMATION: If the information released pertains to alcohol or drug abuse, the confidentiality of the information is protected
by federal law (CFR 42 Part 2) prohibiting you from making any further disclosure of this information without the specific written authorization
of the person to whom it pertains or as otherwise permitted by CFR 42 Part 2. A general authorization for the release of medical or other
information if held by another party is not sufficient for this purpose. The federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient.
REVOCATION:
I, ____________________________ hereby revoke the above Release of information as of:____________________ (date).

____________________________________________ ________________________________________________
Signature of Client Date

____________________________________________ _______________________________________________
Signature of Parent, Guardian, or person authorized Date

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 Akeela House Recovery Center

Resident Information and Responsibilities

 The treatment program runs from 9 to 18 months, seven days a week, and our
professional clinical treatment staff will guide your care for this time period.

 All program materials, including paper and pens will be provided.

 Any medications, prescription or otherwise, not authorized for use will be

confiscated and disposed.

 Total abstinence, free from all mood altering substances, except for prescribed
medications.

 Please wear comfortable, appropriate clothing; no alcohol or drug logos, no

revealing blouses or shirts. Socks and shoes must be worn at all times. No
sleeveless or tank tops may be worn. During business hours, no sweats or
shorts may be worn.

 Please do not wear perfumes, colognes, or other scented products (for the
comfort and the safety of residents and staff who are sensitive to fragrances).

 NO shampoos, mouthwash, hairspray, or other items containing alcohol are

allowed.

 There is no parking available. Please do not bring a vehicle.

 The Akeela House is a non-smoking/tobacco free environment, no tobacco

products are allowed on the premises. Smoking cessation programs are
available. QuitLine services are offered and QuitLine calls can be arranged.

 Supported phone calls are available for client use after completing orientation.
Staff will pass on messages to resident. The following number may be given to
family members who may need to reach you: Treatment Services Main Office
(907) 561-5266 (6:00 a.m. – 10:30 p.m. Sunday to Saturday).

 We believe and encourage the involvement of supportive family and friends.

After Orientation, visitors are welcome after completing one visitation orientation
group and having one meeting with the client and the primary counselor