GRAFTON COUNTY DEPARTMENT OF CORRECTIONS
FIRRM PROGRAM
Pre-Screening Application
_______________________________________________________________________________________________________________________________________________________
The FIRRM Program is an intensive outpatient substance use treatment program for individuals during incarceration. All participants must complete the attached application and agree to the following participant expectations prior to their enrollment.
Practice Cultural Humility
The process of entering a relationship with another person(s) with the intention of honoring their beliefs, customs, and values. It entails an ongoing self-exploration and self-critique combined with a willingness to learn from others.
What’s said in the group stays in group
Feeling safe in group is very important to a successful group experience. Confidentiality is the shared responsibility of all group members and leaders. Please keep discussions that occur in group confidential and keep names and identities of other group members confidential.
Member Participation
As a FIRRM participant you will be expected to make a commitment to attend daily group classes and scheduled individual sessions. If you have an illness that prohibits you from coming to class, you must report to class and inform the program staff of your illness to receive an excused absence. However, an excused absence may require an additional day of FIRRM participation to be eligible for a completion certificate. Only 3 unexcused absences will be permitted in 100 days. Additionally, if an individual is unable to participate due to disciplinary or classification reasons for more than two weeks they will need to restart the program to earn a completion certificate.
Homework is an essential component of FIRRM participation. It is one of the best methods for program staff to evaluate an individual’s progress. If homework is not completed consistently the program staff may recommend discharge or require extended program participation.
During group classes individuals are expected not to engage in disruptive activities such as (crosstalk, private conversations or yelling). At any time if the program staff determine an individual’s behavior is undermining the learning of others, the participant may be asked to leave. If the behavior continues over the course of several group classes, the individual’s group participation may be suspended and possibly be discharged from the FIRRM program.
Demographics:
Name: Date of Birth:
Street Address: City/Town:
State: Zip Code:
County of Residence: SSN#
Home Phone: Cell Phone:
Why are you interested in participating in the FIRRM Program?
Substance Abuse History:
The following 11 questions MUST be answered honestly or risk program disqualification and/or termination.
1. During the past twelve months did you ever notice that the same amount of drugs or alcohol didn’t have the same effect as they used to or that you had to drink more alcohol or use more drugs to get the same effect?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
2. During the past twelve months have you experienced physical distress when you quit drinking or taking drugs, or have you found yourself taking alcohol or a drug to avoid withdrawal symptoms?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
3. During the past twelve months have you used more alcohol or drugs or used over a longer period of time than you had originally planned?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
4. During the past twelve months have you wanted or tried unsuccessfully to cut down or control your substance use?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
5. During the past twelve months have you spent a great deal of time either obtaining, using, or recovering from the effects of alcohol or drugs?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
6. During the past twelve months have you given up any work, family or leisure activities because of your use of a substance?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
7. During the past twelve months have you continued to use alcohol or drugs despite knowing that you have a physical or emotional problem that is either caused by or made worse by your substance use?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
8. During the past twelve months has your use of alcohol or drugs contributed to difficulty or inability to meet responsibilities at home, school or work?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
9. During the past twelve months have you used alcohol or drugs when your use could be putting yourself in physical danger (use while driving, participating in sports, operating heavy machinery etc...)?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
10. During the past twelve months has your alcohol or drug use led to any problems with the legal system such as drunk and disorderly arrest, being picked up for drug possession, etc…?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
11. During the past twelve months have you continued to use alcohol or drugs even though this use has contributed to problems with others such as, arguments with friends or family or physical fights etc…?
DRUGS: YES/NO ALCOHOL: YES/NO BOTH: YES/NO
When was the last time you used drugs or alcohol?
What type of substance?
Have you ever been formally diagnosed with a substance use disorder?
How long have you been using?
Acknowledgement of Limits to my Privacy
I understand that my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records 42 CFR Part 2 and Health Insurance Portability and Accountability Act of 1996 (HIPPA), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without my written consent.
___________________________________________________
Applicant Name Print
___________________________________________________
Applicant Signature Date
*Applications are reviewed once per week by the FIRRM Program Staff – your attorney will be notified or contacted with any decisions or questions.