The Children’s Addiction Prevention Program at Brighton Center for
Recovery
Dear Parents:
Thank you for your interest in the Children’s Program at Brighton Center for Recovery and for giving your
child (ren) this wonderful opportunity!
Please fill out the enclosed paperwork and return to: Brighton Center for Recovery, Children’s
Program, attn: Pat Schafer, 12851 Grand River, Brighton MI 48116. Please include a $50.00 check (per
family) security deposit made payable to “ Brighton Center for Recovery” to secure your place in the
__________________ program. Your deposit will be returned to you when you attend the program.
However, your deposit will be forfeited if you reserved a space for the program, but do not follow
through. Sorry, no exceptions will be made.
Important Information:
• This 3- day program is offered once a month from Friday thru Sunday, 9:00am-3:00pm at the Annex
building on the campus of Brighton Center for Recovery. The Annex building is a separate building,
just right of the main entrance to rehab and the gift shop and is marked as building #5.
• Children will participate all 3 days, and parents will participate all day on Sunday. Parents will also
attend an hour orientation from 9am – 10am on the first day, Friday.
• Please arrive 10 minutes early each day of the program so we can get started right at 9:00am.
• Snacks, beverages and lunch will be served Friday and Sunday. Please inform the staff of any food
allergies ahead of time.
• If children need to take any medications or inhalers, etc. during the program, please give the medication
to the staff with clear directions on how and when your child should take it.
If you have any questions before or during the program, please contact Pat Schafer, LMSW, CAADC
at: 734-255-3191.
We look forward to meeting your family!
Page 1 of 6
Children’s Program Registration Form
Today’s Date:________________________ Program Date:___________________________
Name of Person Completing this Form: ______________________ Relationship to Child: ______________________
Children Participant Information (Please list each child):
1. Child’s Name: ____________________________ Age: ______
Date of Birth: __________ Gender: Female/Male
Is child aware of addiction? Yes/No
Is child seeing a therapist? Yes/No
Child’s 1st time attending this program? Yes/No
Does the child have stomachaches, headaches, sleeping problems, or eating problems? Yes/No
If yes, please describe: __________________________________________________________________________________
Describe any problems your child is having in school:__________________________________________________________
Describe any problems y ou child is having at home:____________________________________________________________
Describe any history of abuse or neglect (physical, sexual, verbal): ______________________________________________
Describe any major life changes within the past year for your child: (Death, separation, moves, etc) ___________________
____________________________________________________________________________________________________
Has your child ever been diagnosed with? Anxiety
Depression
ADD/ADHD
Other: __________________________
Is your child currently on any medications? If so, what medication? _______________________________
2.
Child’s Name: ____________________________ Age: ______
Is child aware of addiction? Yes/No
Date of Birth: __________ Gender: Female/Male
Is child seeing a therapist? Yes/No
Child’s 1st time attending this program? Yes/No
Does the child have stomachaches, headaches, sleeping problems, or eating problems? Yes/No
If yes, please describe: _______________________________________________________________________________
Describe any problems your child is having in school: ________________________________________________________
Describe any problems your child is having at home:__________________________________________________________
Describe any history of abuse or neglect (physical, sexual, verbal): _____________________________________________
Describe any life changes within the past year for your child: (Death, separation, moves, etc)________________________
___________________________________________________________________________________________________
Has your child ever been diagnosed with? Anxiety Depression
ADD/ADHD
Other: _________________________
Is your child currently on any medications? If so, what medication? ____________________________________
3. Child’s Name: ____________________________ Age: ______
Date of Birth: __________ Gender: Female/Male
Is child aware of addiction? Yes/No
Is child seeing a therapist? Yes/No
Child’s 1st time attending this program? Yes/No
Does the child have stomachaches, headaches, sleeping problems, or eating problems? Yes/No
If yes, please describe: _______________________________________________________________________________
Describe any problems your child is having in school: ________________________________________________________
Describe any problems y ou child is having at home:____________________________________________________________
Describe any history of abuse or neglect (physical, sexual, verbal): _____________________________________________
Describe any life changes within the past year for your child: (Death, separation, moves, etc)________________________
___________________________________________________________________________________________________
Has your child ever been diagnosed with? Anxiety Depression ADD/ADHD Other: _________________________
Is your child currently on any medications? If so, what medication? _____________________________
Page 2 of 6
Parent Information/Legal Guardian Information:
Parent/Guardian:
Single
Married
Separated
Divorced
Widowed
Widowed-Remarried
How frequent is visitation with other parent/guardian(s)? ___________________________________________________
If Divorced/Separated, does child(ren) see other parent? Yes/No
Please Explain: ___________________________
_________________________________________________________________________________________________
CPS Referral?
Yes/No
If Yes, please explain:______________________________________________________
Mother’s Name: ___________________________________________________
Address: _______________________________City:___________________ State: _______ Zip Code: __________
County: ____________________
Home Phone #: (____)___________ Cell Phone #:(____)_____________ Work Phone #:(____)____________
E-mail address: ___________________________________________________
In Recovery? Yes/No
If yes, how long in recovery? _______________________________
Former Patient at Brighton Center for Recovery? Yes/No
Currently in Treatment at Brighton Center for Recovery? Yes/No Elsewhere? Yes/No
Drug of Choice:
Alcohol
Opiates (Pain Killers/vicodin/oxycontin/heroin)
Benzodiazepines (Xanax)
Stimulant (Adderall/Cocaine)
Father’s Name: ___________________________________________
Marijuana
Other _________________
Check if Father’s address same as mother
Address: _______________________________City:___________________ State: _______ Zip Code: __________
County: ____________________
Home Phone #: (____)___________ Cell Phone #:(____)_____________ Work Phone #:(____)____________
E-mail address: ___________________________________________________
In Recovery? Yes/No
If yes, how long in recovery? _______________________________
Former Patient at Brighton Center for Recovery? Yes/No
Currently in Treatment at Brighton Center for Recovery? Yes/No Elsewhere? Yes/No
Drug of Choice:
Alcohol
Opiates (Pain Killers/vicodin/oxycontin/heroin)
Benzodiazepines (Xanax)
Stimulant (Adderall/Cocaine)
Page 3 of 6
Marijuana
Other _________________
Other Caregiver/Guardian Name: ___________________________ Caregiver Relationship to Child? ___________________
Address: _______________________________City___________________ State____ County ____________________
Home Phone #: (____)___________ Cell Phone #:(____)_____________ Work Phone #:(____)____________
E-mail address: ___________________________________________________
In Recovery? Yes/No
If yes, how long in recovery? _______________________________
Former Patient at Brighton Center for Recovery? Yes/No
Currently in Treatment at Brighton Center for Recovery? Yes/No Elsewhere? Yes/No
Drug of Choice:
Alcohol
Opiates (Pain Killers/vicodin/oxycontin/heroin)
Benzodiazepines (Xanax)
Stimulant (Adderall/Cocaine)
Marijuana
Other _________________
Family History:
Are there any other family member(s) who have/had a problem?
1. ___________________________________________________ How long was addiction? ________ Months/Years
In Recovery? Yes/No If Yes, How Long? __________ Months/Years
Drug of Choice:
Alcohol
Opiates (Pain Killers/vicodin/oxycontin/heroin)
Marijuana
Benzodiazepines (Xanax)
Stimulant (Adderall/Cocaine) Other _________________
2.
___________________________________________________ How long was addiction? ________ Months/Years
In Recovery? Yes/No If Yes, How Long? __________ Months/Years
Drug of Choice:
Alcohol
Opiates (Pain Killers/vicodin/oxycontin/heroin)
Marijuana
Benzodiazepines (Xanax)
Stimulant (Adderall/Cocaine) Other _________________
Additional Information:
Please describe any concerns you may have about your child(ren)? _____________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
How do you hope the Children’s Program will benefit your child(ren) and you? _________________________
_________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Page 4 of 6
Other information you would like the Children’s Program staff to know to better assist your child(ren): __________________
________________________________________________________________________________________________
_________________________________________________________________________________________________
Location you and your child(ren) will be staying during the program: _________________________________________
Person’s name who filled out this form: __________________________ Relationship to Child: ___________________
Who referred your family to the Children’s Program?
Name of Referent: ___________________________________________
Address: ____________________________________________
City/State:___________________________________________ Zip Code:________________
Referent Phone #: ____________________________________
Participation in Children’s Program on Sunday
(check all that apply)
Mother
Father
Grandparent
Guardian
Other __________________________
Page 5 of 6
Brighton Center for Recovery
Children’s Addiction Prevention Program
Consent to Participate
I consent to allow my child to participate in The Children’s Addiction Prevention Program at Brighton Center for
Recovery:
_____________________________________________________________________________________________
Name of Minor
Birth Date
_____________________________________________________________________________________________
Print Name of Parent(s) or Guardian(s)
____________________________________________ _______________________________________________
Signatures Parent(s) or Guardian(s)
_________________________________________________
____________________________________
Name of Emergency Contact Person (Relationship to Minor)
Emergency Contact Phone #
I am aware that participation in the Children’s Program at Brighton Center for Recovery involves certain activities
(such as, physical play activities) which are physically demanding and potentially dangerous for children. Therefore,
as a participant, my child must be free of medical or physical conditions which might create undue risk. I understand
that physical strength is not necessary, although being in good physical condition will increase enjoyment of the
activities.
I am aware that these activities involve a potential risk for illness and injury to my child and property. I acknowledge
that I am aware of and assume all risks and wish to allow my child to participate in the activities. As part of the
consideration for my child’s participation in the Children’s Program, I agree to assume full responsibility for any loss,
injury, or inconvenience that my child might suffer. To the extent that I participate in such activities, I further agree to
indemnify and hold harmless Brighton Center for Recovery and all its subsidiaries and officers from any and all
liability incurred as a result of participation by myself or my child. I also agree that the terms hereof shall serve as a
release and assumption of risk for my heirs, executors and administrators, and for all members of my family.
I am aware and accept my responsibility to comply with any custodial arrangements that might exist with another
parent or legal guardian who has the legal right to make decisions in our child’s life.
Medical Information: It is necessary for us to know if your child has any medical considerations. If not, please write
“no”; if so, please write “yes”. Please describe in detail and send any medications with your child to Brighton Center
for Recovery. You may write long answers on the back of the form. Please initial and date information on the back.
Chronic Medical Condition (i.e., diabetes, asthma, seizures, etc.)
_____________________________________________________________________________________________
Allergic Reactions (i.e., to insect bites, stings, or poison oak? to any medications?)
_____________________________________________________________________________________________
Any Surgery, Sprained Muscles, or Broken Bones within the Past 12 Months? Yes or No (circle one)
Authorization to treat a minor: In the event I cannot be reached in an emergency, I hereby give permission to the
person named as emergency contact to authorize medical and hospital care of my child and if such person cannot be
reached, I give permission to the physician on-call at Providence Park Hospital to hospitalize, secure proper treatment
for, and to order injections, anesthesia, or surgery for my child as named above.
By signing this form I acknowledge that I have had the opportunity to read this form (or have it read to me), ask
questions and have these questions answered. I understand and agree to the statements on this form.
_____________________________________________________
Signature (Parent/Legal Guardian must sign for persons under 18)
Page 6 of 6
____________________________________
Date