This is to verify that I have read and understand
this admission agreement and attached documents as
listed below and agree to the terms and conditions
contained herein.
- Admission Policy
- Program Plan
- Program Rules
- Housekeeping and Safety Provisions
- Client bill of Rights and Complaint Procedure
- Program Expectations, Responsibilities and Restrictions
The agreed rate for my resident fee is $_______ per
day. Arrangement for payment is as follows: (Indicate
specific County, V. A. Contract, Self, etc.)
The rate begins on the day of admission and is continuous
until day of discharge. The resident fee includes
all charges for program and service routinely provided
through the program. Other expenses, such as psychological
consult fees, medical, dental charges and purchase
for personal grooming, including clothing and the
laundering of clothing, are the sole responsibility
of the client, and will not be assumed by Kinnic Falls.
Any additional charges or adjustments in the fee
payment arrangement will be mutual understanding prior
to the effective date of change. Refunds will reflect
the difference between the advance payment and actual
charges for time in residence, based on the daily
rate.
Personal effects that are left behind will be placed
in storage for thirty (30) days and will then be disposed
of if not claimed. Kinnic Falls assumes no liability
for clients’ personal items.
Admission to Kinnic Falls and participation in any
treatment and rehabilitation program, sports, recreational
or other activities is voluntary and Kinnic Falls
assumes no liability for personal loss or injury resulting
from such participation.
I fully understand that by signing this admission
agreement, I acknowledge that I have been informed
of all conditions listed above and consent to abide
by these conditions.
I also understand that this consent to treatment
is effective immediately and remains in effect until
the scheduled discharge date unless I voluntarily
withdraw it sooner in writing.
___________________________________
Kinnic Falls Alcohol and Drug Abuse Services, Inc.
Staff Signature
___________________________________
Client or Guardian Signature
______________
Date
admissions
policy
