New Client Registration Form

Bloom Recovery Network Intake Form

Please fill in the form below
Name*

First Name Last Name
Today's Date*

MonthDay Year
Date
E-mail
Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Contact Number*

Area Code Phone Number
Sex*
Date of Birth*

Month Day Year
Do you need a handicap accessible room?

NoYes
Please list any other special needs, including any food allergies
Month you wish to attend DIP:*
Would you like a single room occupancy? *
Has the court ordered a specific completion date? If so, please specify:

MonthDay Year
Date
Emergency Contact

List someone who can be contacted in the event of an emergency.
EMGERGENCY CONTACT NAME*

First Name Last Name
EMERGENCY CONTACT RELATIONSHIP TO YOU*
EMERGENCY CONTACT ADDRESS*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
EMERGENCY CONTACT PHONE NUMBER*

Area Code Phone Number
Sentencing Court:*
Sentencing Judge:*
Case Number:*
Attorney contact information if you wish to have information shared:
Authorization for Release of Information will need to be signed prior.
Signature-Form completed by:*

By signing above, I agree that the signature will be an electronic representation of my signature for all purposes when I use them on this document. Clear
YOU ARE NOT CONSIDERED REGISTERED UNTIL DEPOSIT IS PAID. ONCE PAYMENT IS RECEIVED, ALONG WITH THE INTAKE & CONSENT FOR RELEASE; WE WILL CONTACT THE COURTS.

Once registration and payment are received you will be contacted by Bloom Recovery Network closer to the program date you choose.

Bloom Recovery Network, LLC Authorization For Disclosure Of Confidential SUD Patient Records
I,
Client Name*

First Name Last Name
Client Date of Birth:

MonthDay Year
Date
authorize Bloom Recovery Network LLC to disclose Registration letter, attendance of lack of attendance, participation (understanding of objectives, behavior/response), cooperation with the DIP program rules and expectations, Program Completion Report, Certificate of Completion
[describe how much and what kind of information may be disclosed, including an explicit description of any substance use disorder information to be disclosed: should be as limited as possible]
TO*
Type the name of your sentencing court.
Please email bloomrecovery@gmail.com if the Authorization for Disclosure of Confidential SUD Records included in this registration process does not accurately reflect the following:

-How much and what kind of information you want disclosed,
-The purpose for that disclosure
-The date, event or condition upon which the consent will expire,
-OR disclosure to any other person or agency beyond your sentencing court (such as an Attorney, PO, other referring agency or individual)

This Authorization for Disclosure form is specific to your sentencing court and disclosure of the information we are required (or may be requested) to provide.
For the purpose of informing the criminal justice agency(or other) listed above of MY DRIVER'S INTERVENTION PROGRAM compliance or non-compliance.
[describe the purpose of the disclosure; should be as specific as possible]
This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose (see 42 CFR 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 42 CFR 2.12(c)(5) and 42 CFR 2.65.
I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows:*

there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment/prevention (DIP) OROther
If selected "other" above:
[date, event, or condition upon which consent will expire, which must be no longer than reasonably necessary to serve the purpose of this consent]
I understand that I may be denied services if I refuse to consent to disclosure for purposes of treatment, payment, or healthcare operations, if peremitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I have been provided a copy of this form.
Today's Date*

MonthDay Year
Date
Signature of defendant/client:*

By signing above, I agree that the signature will be an electronic representation of my signature for all purposes when I use them on this document. Clear
Signature of person signing form if not patient:

By signing above, I agree that the signature will be an electronic representation of my signature for all purposes when I use them on this document. Clear
IF SIGNING ON BEHALF OF THE PATIENT:
Describe authority to sign on behalf of patient
Payment Options Below

ALL PROGRAMS MUST BE PAID IN FULL 7 DAYS PRIOR TO THE PROGRAM START DATE.
PAYMENT OPTIONS
prevnext( X )
Initial Deposit$50.00

2022-DOUBLE ROOM Full Fee$400.00

2022-DOUBLE ROOM Payoff (after -$50 deposit)$350.00

2022-SINGLE ROOM Full Fee$525.00

2022-SINGLE ROOM Payoff (after -$50 deposit)$475.00

ROOM UPGRADE from a single to a double.$125.00
Only select this option if you have already paid in full for a double room and want to change to a single room.

Subtotal $0.00Shipping $0.00Total $0.00
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The payment is ready! It will be completed once you submit the form.
MAKE PAYMENT ABOVE. ONCE PAYMENT IS MADE. THE FORM WILL AUTOMATICALLY BE SUBMITTED.

ONLY HIT THE "SUBMIT" BUTTON IF YOU HAVE PREVIOUSLY PAID VIA PHONE, IN PERSON, ETC
Should be Empty:

Bloom Recovery Network Intake Form

Emergency Contact

YOU ARE NOT CONSIDERED REGISTERED UNTIL DEPOSIT IS PAID. ONCE PAYMENT IS RECEIVED, ALONG WITH THE INTAKE & CONSENT FOR RELEASE; WE WILL CONTACT THE COURTS.

Bloom Recovery Network, LLC Authorization For Disclosure Of Confidential SUD Patient Records

I,

Payment Options Below

MAKE PAYMENT ABOVE. ONCE PAYMENT IS MADE. THE FORM WILL AUTOMATICALLY BE SUBMITTED.