Internet Addiction Recovery Program APPLICATION ... - HEAL

Internet Addiction Recovery Program 

APPLICATION PACKAGE 

• Welcome Letter 

• Participant Data 

• Presenting Concern 

• Participant History 

• Family Information 

• Release of Information 

• Notice of Privacy Practices 

• Acknowledgement of Receipt 

• Medical Insurance Info 

• Personal Health History 

• Immunization Record 

• Physical Examination 

• Prescription Medication 

• Recovery Agreement 

• Assumption of Risk 

• Screening Interview Prep 

• What to Bring 

• Transportation 

Prior to the SCREENING INTERVIEW Appointment: 

(1) Review the Welcome Letter 

(2) Complete the Application Package Forms in its entirety (Keep a copy for yourself) 

(3) Have a physician complete the Physical Examination and Fax Lab Reports to (425) 222‐7189 

(4) Read, sign and date the Recovery Agreement (Keep a copy for yourself) 

(5) You may review the Notice of Privacy Practices (NPP) 

(6) Read, sign and date the Acknowledgment of Receipt of NPP 

(7) Preview the Screening Interview Preparation Form 

Please send your completed application along 

with the application processing fee to: 

reSTART Internet Addiction Recovery Program 

1001 ‐ 290 th Ave SE 

Fall City, WA 98024‐7403 Application Processing Fee $ 200 

This non‐refundable fee is due prior to arrival for 2‐day Screening Interview Fee $ 800 

the initial placement interview. 

Due prior to formal admission into the program 45‐day Program Fee $ 14,500 

PARTICIPANT FUND ACCOUNT ($35 per day) 

Unused portion (minus $500 stipend for 

active involvement to participant if earned) 

remaining amount is refundable at program 

completion 

$ 1,575 

If you have any questions regarding these forms, please don’t hesitate to email or call. Please leave a message 

as staff is generally in session throughout the day. 

Page | 1 

reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 

restart@netaddictionrecovery.com | www.netaddictionrecovery.com


WELCOME 

The reSTART Internet Addiction Recovery Program is specifically oriented towards launching tech 

dependent youth and adults back into the real world. Our individually tailored program is designed to assist 

participants with an internet and/or computer based behavioral addiction to break the cycle of 

dependency. Our 45‐day individualized abstinence based recovery program exposes participants to a 

variety of activities and everyday life skills which are often avoided or underdeveloped as a result of 

ongoing computer, video game play and internet abuse. 

Meet the Program Founders 

Hilarie Cash, Ph.D., Executive Director 


Co‐founder of Internet/Computer Addiction Services and codeveloper 

of the Gaming and Internet Treatment Program. 

Hilarie is a speaker, teacher, and author and has appeared, 

among other places, on ABC News, CNN, NPR, PBS, the BBC, and 

in print in the Seattle Times, U.S.A. Today, U.S. News and World 

Report, and the New York Times. She has been in private 

practice for 25 years. 

Cosette Dawna Rae, MSW, Executive Director 


Cosette is a psychotherapist, personal life coach, and stress 

management therapist specializing in the treatment of stress, 

anxiety, trauma and addictions. As a former IT professional with 

20+ years experience in computer/internet technology, she 

understands the intricate nature of tech addiction and the 

tools necessary to bring about desired change. Cosette is a 

graduate of the University of Washington and Founder of 

Heavensfield Retreat Center. 

Page | 2 




PARTICIPANT DATA 

Participant ID ____________________________ Date ________________________ Counselor Assigned ________________________________ 

Referred by Self Clergy Friend Family Healthcare provider Other ________________ Phone __________________________ 

Participant Name ______________________________ MI _______ Last Name ______________________ Maiden ____________________ 

Student Address _____________________________________________________________________________________________________________ 

City ____________________________ State ________ Zip _________ Is student living at this address Yes No 

Cell Phone __________________________ Message Phone ____________________________________ Email __________________________________ 

Age _________ Date Of Birth ____________________________ Adopted Yes No Gender Male Female 

Height ____________________ Weight _________________ Shirt size __________________ Pant Size ________________ Shoe Size ______________ 

Ethnicity 

Asian/Pacific Islander White American Indian Hispanic African American Black International Student 

Religious 

Preference 

Christian Catholic Jewish Protestant LDS None, but I believe in God Atheist Other _____________ 

Parent Relationship Status Single Engaged Married Separated Divorced Widowed 

Father’s Name __________________________ MI ________ Last Name ______________________ Maiden ________________ 

Address __________________________________________________________________________________________________________________ 

City _____________________________ State __________ Zip _________ Is student living at this address Yes No 

Home Phone ________________________ Cell Phone ______________________Email Address ________________________________________ 

Employer__________________________________________________________________Work Phone ___________________________________ 

Mother’s Name __________________________ MI ________ Last Name ____________________________ Maiden ________________ 

Address __________________________________________________________________________________________________________________ 

City _____________________________ State __________ Zip _________ Is student living at this address Yes No 

Home Phone ________________________ Cell Phone ______________________Email Address ________________________________________ 

Employer__________________________________________________________________Work Phone ____________________________________ 

Step Mother’s Name _________________________ Home Phone _______________ Cell phone _______________ Email ______________________ 

Step Father’s Name _________________________ Home Phone _______________ Cell phone _______________ Email ______________________ 

Emergency Contact Information: 

Contact Name ______________________________ Home Phone ________________ Cell phone ______________ Email _______________________ 

Contact Name ______________________________ Home Phone ________________ Cell phone ______________ Email _______________________ 

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PRESENTING CONCERN/PROBLEM 

Provided by ________________________________________ 

Briefly list your concerns in order of priority. 

1. _________________________________________________________________________________________________________ 

2. _________________________________________________________________________________________________________ 

3. _________________________________________________________________________________________________________ 

4. _________________________________________________________________________________________________________ 

Any previous involvement in counseling or treatment Yes No 

When was the problem first noted, and by whom (Include age/grade, sudden or gradual, noticed personally or brought to attention 

by someone else) ____________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

___________________________________________________________________________________________________________ 

How often does the problem occur, and in what settings ____________________________________________________________ 

___________________________________________________________________________________________________________ 

What is the intensity/severity of the behavior _____________________________________________________________________ 

___________________________________________________________________________________________________________ 

What are the typical antecedents to the behavior _________________________________________________________________ 

__________________________________________________________________________________________________________ 

Is the behavior usually in response to some event or provocation (e.g., person, setting, situation, time of day, event), or does it appear 

to happen for no reason ____________________________________________________________________________________ 

__________________________________________________________________________________________________________ 

What is the variability in the behavior across time, settings, people, etc. (e.g., preset, cyclic) ______________________________ 

__________________________________________________________________________________________________________ 

What typically happens after the behavior occurs ________________________________________________________________ 

What are the typical consequences ____________________________________________________________________________ 

What have parents tried to do to modify consequences and what have been the results _________________________________ 

__________________________________________________________________________________________________________ 

How consistent have parents’ reactions been ___________________________________________________________________ 

What effect does the problem have on others; what is the level and type of impairment associated with the problem 

_________________________________________________________________________________________________________ 

_________________________________________________________________________________________________________ 

What are short‐term and long‐term consequences _______________________________________________________________ 

_________________________________________________________________________________________________________ 

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PARTICIPANT HISTORY 

Please read the following questions pertaining to the participant and mark the checkbox with those to which you would respond “yes” 

and explain. 

EDUCATIONAL HISTORY 

Last Grade Completed 7 th 8 th 9 th 10 th 11 th 12 th College Freshman Sophomore Junior Senior Grad School 

Has participant earned his/her high school diploma or GED Yes No _____________________________________________________________ 

Currently attending school Yes No if yes, where 

___________________________________________________________________________ 

Are these concerns interfering with participant’s ability to attend school Yes No ___________________________________________________ 

Is this problem interfering with academic performance Yes No __________________________________________________________________ 

MENTAL/BEHAVIORAL HEALTH HISTORY: 

Diagnosis How is this being managed Diagnosis How is this being managed 

ADD/ADHD ______________________________________ Depression _____________________________________ 

Asbergers ______________________________________ Anxiety _____________________________________ 

Autism ______________________________________ PTSD _____________________________________ 

ODD ______________________________________ Bi‐polar _____________________________________ 

OCD ______________________________________ _____________ _____________________________________ 

Describe other mental/emotional concerns not listed above ________________________________________________________________ 

 

 

Is there a history of being hospitalized for mental health reasons _________________________________________________________________ 

Is there a history of mental health issues in the family Please explain ______________________________________________________________ 

CURRENT/PAST HISTORY OF SUBSTANCE USE: 

Substance used Date of last use Frequency per week Substance used Date of last use Frequency per week 

Tobacco _______________ ____ Packs per day Speed ______________ _______________ 

Chew _______________ _______________ Ecstasy ______________ _______________ 

Marijuana _______________ _______________ Cocaine ______________ _______________ 

Alcohol _______________ _______________ Crack ______________ _______________ 

Energy Drinks _______________ _______________ Speed ______________ _______________ 

Caffeine _______________ _______________ Heroin ______________ _______________ 

_____________ _______________ _______________ Meth ______________ _______________ 

_____________ _______________ _______________ _____________ ______________ _______________ 

Any illegal substances use not listed above _______________________________________________________________________________ 

 

 

Prescription drug use (not prescribed to student) If so, what _______________________________________________________________ 

Is there a history of alcohol or drug problems in the family Please explain__________________________________________________________ 

______________________________________________________________________________________________________________________ 

Page | 5 



PARTICIPANT HISTORY (Continued) 

TRAUMA HISTORY (Check all that apply) 


Anxious Hyper vigilant Nightmares Sleeplessness Phobias 

Prefers Isolation Depressed Shy/Withdrawn Dissociates Avoidant 

Headaches Stomachaches Under eating Over eating Binge eating 

Conduct Problems Peer problems Irritable/Angry Bullying Hyperactivity 

Low impulse control Violent behavior Running Away Lying Stealing 

Sexually acting out Low Self‐Esteem Lacks Empathy Distracted Homicidal Thoughts 

Participant is a survivor of 

Sexual assault Physical abuse Verbal abuse Emotional/Psychological Abuse Car Accident War/Veteran 

Serious Illness/Disability Divorce Multiple Relocations Loss of Home Natural Disaster Death in the Family 

 

 

Past history of suicide attempts Please describe ________________________________________________________ How many ___________ 

Does participant report feeling hopeless ___________________________________________________________________________________ 

STRESS 

List the types of stresses participant experiences (family, work, relationship, self, health etc.) 

____________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________ 

How does participant handle stress ______________________________________________________________________________ 

LEGAL HISTORY 

Is there a history of legal trouble If so, please describe _________________________________________________________________________ 

Has there been an arrest If so, for what ____________________________________________________________________________________ 

Participant is on probation. If so, what are the requirements _____________________________________________________________________ 

Have any other family members experienced legal problems If so, who and what __________________________________________________ 

EMPLOYMENT HISTORY 

Participant is currently employed. Employer’s name ___________________________________________________________________________ 

Job Title _________________________________________________ Length of employment _________________________________________ 

Participant has been terminated from a previous job. If so, describe ______________________________________________________________ 

RELATIONSHIPS 

Is participant involved in a romantic relationship Yes No Please list important people and friends in participant’s life: 

Name City State Phone 

Page | 6 




FAMILY INFORMATION 

Describe biological Father’s relationship with participant ____________________________________________________ 

__________________________________________________________________________________________________ 

Describe Step‐Father’s relationship with participant _______________________________________________________ 

_________________________________________________________________________________________________ 

Describe biological Mother’s relationship with participant __________________________________________________ 

_________________________________________________________________________________________________ 

Describe Step‐Mother’s relationship with participant ______________________________________________________ 

_________________________________________________________________________________________________ 

Which family member’s is participant closest to _________________________________________________________ 

Which family relationship is most strained ______________________________________________________________ 

Does participant have brothers or sisters □ No □ Yes 

Siblings‘ 

Names 

Age 

Current 

Grade 

Difficulties in learning or other disabilities (describe) 

Other significant information about this participant’s family 

What current problems exist in the family unit ____________________________________________________________ 

___________________________________________________________________________________________________ 

Is the family experiencing in current/past stressors _________________________________________________________ 

___________________________________________________________________________________________________ 

Please describe your family’s strengths ___________________________________________________________________ 

___________________________________________________________________________________________________ 

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RELEASE OF INFORMATION 

I hereby authorize that health care information for: 

LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME PERSONAL ID#(PID) *SOCIAL SECURITY NUMBER 

BE MUTUALLY EXCHANGED between reSTART Internet Addiction Recovery program and 

LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME RELATIONSHIP TO APPLICANT 

PERMANENT ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER 





For the purpose of: 

_____ Diagnosis and treatment 

_____ Psychological evaluation 

_____ Coordination of care/Verbal updates 

_____ Other: _____________________ 

I understand: 

(1) That my records are protected under Federal and State statutes and cannot be disclosed without my written consent unless 

otherwise provided for in the statutes. 

(2) That I may revoke this consent, in writing, at any time except to the extent that action has already been taken relative to it. 

(3) That my specific permission is required to release any health care information regarding testing, diagnosis or treatment for HIV 

(AIDS virus), communicable/sexually transmitted diseases, psychiatric disorders, mental health, drug or alcohol treatment. 

(4) That a photocopy of this consent shall have the same effect as the original. 

________________________________ _____________ ______________________________ ___________ 

(Signature of Applicant) (Date) (If Minor, Signature of Guardian) (Date) 

________________________________ _____________ 

(Signature of Parent or Guardian) (Date) 

Page | 8 




NOTICE OF PRIVACY PRACTICES 

This notice describes how health information about you may be 

used and disclosed and how you may obtain access to this 

information. Please review it carefully. 

YOUR HEALTH INFORMATION MAY BE USED AS FOLLOWS: 

For APPOINTMENTS AND SERVICES as a reminder of upcoming 

appointment(s), or to let you know about alternatives in treatment, 

health related services or benefits. 

For TREATMENT your information may be provided to other health care 

providers to facilitate your treatment, referrals or consultations. 

For PAYMENT we may contact your insurer to verify your benefits, 

obtain appropriate authorization and receive payment from you 

insurance carrier or 3 rd party payer. 

For HEALTHCARE OPERATIONS as a service to you, information may be 

shared with a supervisor to review the quality of care provided, for 

performance improvement or for training of health professionals. 

To INDIVIDUALS INVOLVED IN YOUR CARE such as parents, or a 

conservator, or as designated by you with written permission. 

WITH YOUR WRITTEN PERMISSION we may disclose health information 

for purposes not described in this Notice only with your written 

authorization. 

YOUR HEALTH INFORMATION MAY BE USED WITHOUT YOUR WRITTEN 

AUTHORIZATION 

AS REQUIRED BY LAW if required or authorized by other laws, such as 

the mandatory reporting of child abuse, elder abuse or dependent adult 

abuse. 

To PUBLIC HEALTH OFFICIALS to prevent or control communicable 

disease, injury or disability, or ensure the safety of drugs and medical 

devices. 

In LEGAL PROCEEDINGS in response to court or administrative orders, 

subpoenas, discover request or other legal process. 

To LAW ENFORCEMENT for example, to assist in an involuntary 

hospitalization process. 

As a PREVENTION OF SERIOUS THREAT TO SAFETY OR HEALTH of an 

individual. We may notify the person, tell someone who could prevent 

the harm, or tell law enforcement officials. 

For HEALTH OVERSIGHT ACTIVITIES to governmental, licensing, auditing, 

and accrediting agencies as authorized and required by law including 

audits; civil, administrative or criminal investigations; licensure or 

disciplinary actions; and monitoring of compliance with law. 

YOU HAVE THE FOLLOWING RIGHTS: 

To RECEIVE THIS NOTICE when you are receiving care. 

To REQUEST RESTRICTIONS. You have the right to request a restriction 

or limitation on the mental and physical health information we disclose 

about you for treatment, payment or health care operations. You must 

put your request in writing. We are not required to agree with your 

request. If we do agree with the request, we will comply with your 

request except to the extent that disclosure has already occurred or if 

you are in need of emergency treatment and the information is needed 

to provide the emergency treatment. 

To INSPECT AND REQUEST A COPY OF YOUR MENTAL HEALTH RECORD 

except in limited circumstances. A fee will be charged to copy your 

record. You must put your request for a copy of your records in writing. 

If you are denied access to your mental health record for certain 

reasons, we will tell you why and what your rights are to challenge that 

denial. 

To REQUEST THAT WE CONTACT YOU BY ALTERNATE MEANS (e.g., fax 

versus mail) or at alternate locations. Your request must be in writing 

and we must honor reasonable requests. 

To REQUEST AN AMENDMENT AND/OR ADDENDUM to your Health 

Record. If you believe that information is incorrect or incomplete, you 

may ask us to amend the information or add an addendum (addition to 

each record) of no longer than 250 words for each inaccuracy. Your 

request for amendment and/or addendum must be in writing and give a 

reason for the request. We may deny your request for an amendment if 

the information was not created by us, is not a part of the information 

which you would be permitted to inspect and copy, or if the information 

is already accurate and complete. Even if we accept your request, we do 

not delete any information already in your records. 

To RECEIVE AN ACCOUNTING OF CERTAIN DISCLOSURES we have made 

of your health information. You must put your request for an accounting 

in writing. 

To REQUEST THAT WE CONTACT YOU BY ALTERNATE MEANS (e.g., fax 

versus mail) or at alternate locations. Your request must be in writing 

and we must honor reasonable requests. 

CHANGES TO THIS NOTICE: We reserve the right to change this Notice. 

We reserve the right to make the revised or changed Notice effective for 

information we already have about you as well as any information we 

receive in the future. An updated copy will be posted on the 

Heavensfield website. 

If you believe your privacy rights have been violated, you may file a 

complaint with the Secretary of the Department of Health and Human 

Services. 

YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT. 

Amended Effective Date: June 7, 2009 

Page | 9 




ACKNOWLEDGMENT OF RECEIPT of the Notice of Privacy Practices 

I acknowledge that I have received or been offered the Notice of Privacy Practices of the reSTART Internet 

Addiction Recovery Program. I understand that the Notice describes the uses and disclosures of my protected 

health information by the Covered Entities and informs me of my rights with respect to my protected health 

information. 

_____________________________________________________________________ 

Name of Participant 

_________________________________ 

Medical Record Number 

_________________________________ 

Date of Birth 

_____________________________________________________________________ 

Signature of Participant or Personal Representative 

_____________________________________________________________________ 

Printed Name of Participant or Personal Representative 

_____________________________________________________________________ 

Date 

If Personal Representative, indicate relationship: 

_____________________________________________________________________ 

Declinations 

______ 

______ 

The Individual declined to accept a copy of the Notice of Privacy Practices. 

The Individual received a copy of the Notice of Privacy Practices but declined to sign an 

Acknowledgment of Receipt. 

___________________________________ 

Signature of reSTART Representative 

_________________________________ 

Name of reSTART Representative 

Page | 10 




MEDICAL INSURANCE INFORMATION 

ID NUMBER – Copy from your health insurance identification card 

GROUP NUMBER: 

IDENTIFCATION NUMBER: 

PATIENT INFORMATION 

PARTICIPANTS FULL LEGAL NAME (Last, First, Middle) 

Sex 

Male 

Female 

SOCIAL SECURITY 

NUMBER (Optional) 

/ / 

PATIENT IS: Member Spouse Child Other. Please explain relationship: 

IF CLAIM IS FOR CHILD 19 OR OLDER‐IS CHILD: A full‐time student Yes No Disabled Yes No 

DATE OF BIRTH 

Month Day Year 

| | 

PAYEE: 

MAKE PAYMENT TO THE PROVIDER (HOSPITAL, DOCTOR ETC.), OR 

MAKE PAYMENT OT MEMBER, THE PROVIDER HAS BEEN PAID 

MEMBER INFORMATION 

MEMBERS FULL LEGAL NAME (Last, First, Middle) 

CURRENT ADDRESS: 

IF COVERAGE IS THRU YOUR 

EMPLOYER, PROVIDE 

Group (Employer name) 

Sex 

Male 

Female 

SOCIAL SECURITY 

NUMBER (Optional) 

/ / 

DATE OF BIRTH 

Month Day Year 

| | 

HOME PHONE: 

(____) 

WORK PHONE: 

(____) 

OTHER INSURANCE INFORMATION 

Are there OTHER medical benefits available to you, your spouse, or your dependents form OTHER Group Insurance, including OTHER 

employers, Labor or Professional Organizations, schools Yes No 

POLICY HOLDER NAME: 

POLICY HOLDER IS: Member Spouse Child OTHER, please explain relationship 

INSURANCE CARRIER NAME: POLICY NUMBER: EFFECTIVE DATE: 

SOCIAL SECURITY NUMBER 

(Optional) 

/ / 

ADDRESS: 

PHONE NUMBER: 

(____) 

RELEASE OF INFORMATION: I certify that the above information is correct to the best of my knowledge. I understand that use or 

disclosure of individually identifiable health information, whether furnished by me or obtained from other sources such as medical 

providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability and Accountability Act 

of 1996). 

A copy of the front and back of the medical insurance card is attached to this application. 

Sign 

HERE ____________________________________________________________________ Date ______________________________ 

Signature of Member 

Page | 11 



PERSONAL HEALTH HISTORY of PARTICIPANT 




DATE OF BIRTH (mo/day/yr) 

GENDER M F Height __________ Weight _________ 

NAME OF PERSON TO CONTACT IN CASE OF EMERGENCY 

RELATIONSHIP 

ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER 

The following health history is confidential, does not affect your admission status and, except in an emergency situation or by court order, will not 

be released without your written permission. Please attach additional sheets for any items that require fuller explanation. 

Has any person, related by blood, had any of the following: 

High blood pressure 

Stroke 

Heart attack before age 

55 

Blood or clotting disorder 

Yes No Relationship 

Cholesterol or blood 

fat disorder 

Diabetes 

Glaucoma 


Cancer (type): 

Alcohol/drug problems 

Psychiatric illness 

Suicide 


Have you ever had or have you now: (please check at right of each item and if yes, indicate year of first occurrence) 

Yes No Year 

Yes No Year 

Yes No Year 

High blood pressure 

Hay fever 

Jaundice or hepatitis 

Rheumatic fever 

Allergy injection 

therapy 

Rectal disease 

Arthritis 

Heart trouble or 

disease 

Pain or pressure in 

chest 

Shortness of breath 

Asthma 

Pneumonia 

Chronic cough 

Head or neck radiation 

treatments 

Tumor or cancer 

(specify) 

Malaria, Typhoid, or 

Scarlet Fever 

Thyroid trouble 

Diabetes or 

Hypoglycemia 

Serious skin disease 

Mononucleosis 

Concussion 

Frequent or severe 

migraine or headache 

Dizziness or fainting 

spells 

Severe head injury 

Paralysis 

Disabling depression 

Excessive worry or 

anxiety 

Ulcer (duodenal or 

stomach) 

Intestinal trouble 

Pilonidal cyst 

Frequent vomiting 

Gall bladder trouble or 

gallstones 

Severe or recurrent 

abdominal pain 

Hernia 

Easy fatigability 

Anemia or Sickle Cell 

Anemia 

Eye trouble besides 

need glasses 

Bone, joint, or other 

deformity 

Knee or ankle 

problems 

Recurrent back pain 

Neck injury 

Back injury 

Broken bones 

(specify) 

Kidney infection 

Bladder infection 

Kidney stones 

Protein or blood in 

urine 

Hearing loss 

Sinusitis 

Severe menstrual 

cramps 

Irregular periods 

Sexually 

transmitted disease 

Blood transfusion 

Obesity 

Drug Treatment 

Anorexia/Bulimia 

Smoke 1+ pack 

cigarettes/week 

Glasses or 

Contacts 

Serious operation 

or illness 

Other (specify) 

Yes No Year 

Please list any drugs, medicines, birth control pills, vitamins, minerals, and any herbal/natural product (prescription and nonprescription) you use and how often you use them. 

Name Use Dosage Name Use Dosage 




Provision of Social Security number is voluntary, is requested solely for administrative convenience and record‐keeping accuracy, and is requested 

only to provide a personal identifier for the internal records of this program. 

Page | 12 




PERSONAL HEALTH HISTORY of PARTICIPANT (Continued) 

Check each item “Yes” or “No.” Every item checked “Yes” must be fully explained in the space on the right (or on an attached sheet). 

Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following If yes, 

please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once. 

Adverse Reactions to: Yes No Explanation 

Penicillin 

Sulfa 

Other antibiotics (name) 

Aspirin 

Codeine 

Other pain relievers 

Other drugs, medicines, 

chemicals (specify) 

Insect bites 

Food allergies (name) 

Do you have any conditions or 

disabilities that limit your physical 

activities (If yes, please describe) 

Have you ever been a patient in 

any type of hospital (Specify 

when, where, and why) 

Has your academic career been 

interrupted due to physical or 

emotional problems (Please explain) 

Is there loss or seriously impaired 

function of any paired organs 

(Please describe) 

Other than for routine check‐up, 

have you seen a physician or 

health‐care professional in the 

past six months (Please describe) 

Have you ever had any serious 

illness or injuries other than those 

already noted (Specify when and 

where and give details) 

Yes No Explanation 

Signature of Student 

Date 

Signature of Parent or Guardian (if student under age 18) 

Date 

Page | 13 




IMMUNIZATION RECORD 


SECTION A ‐ REQUIRED IMMUNIZATIONS 

mo./day/year mo./day/year mo./day/year mo./day/year 

• DTP or Td (#1) (#2) (#3) (#4) 

• Td booster 

• Polio 

• MMR (after first birthday) 

• MR (after first birthday) 

• Measles (after first birthday) 

**Disease Date ****Titer Date & Result 

• Mumps 

• Rubella 

***(Disease Date NOT 

Accepted) 

***(Disease Date NOT 

Accepted) 

****Titer Date & Result 


SECTION B ‐ RECOMMENDED IMMUNIZATIONS 

The following immunizations are recommended for all participants. 

Meningococcal Received the meningococcal vaccine No Yes 

If Yes, please indicate date(s) vaccine was received (mo./day/year) 

• Hepatitis B series only 

month/day/year month/day/year month/day/year 


• Hepatitis A/B combination series 

• Varicella (chicken pox) series of two doses or 

immunity by positive blood titer 

• Tuberculin (PPD) Test 

Date read 

(within 12 months) mm in duration 

Chest x‐ray, if positive PPD 

Date 

Results 

Treatment if applicable 

Date 

SECTION C ‐ OPTIONAL IMMUNIZATIONS 

• Haemophilus influenzae type b 

• Pneumococcal 

• Hepatitis A series only 

• Other 

Disease Date 

month/day/year month/day/year month/day/year 


Signature of Physician/Physician Assistant/Nurse Practitioner 

Date 

Print Name of Physician/Physician Assistant/Nurse Practitioner 

Area Code/Phone Number 

Page | 14 




PHYSICAL EXAMINATION 


TO THE PHYSICIAN: 

The program for which this individual is applying may include rigorous physical activity in a wilderness setting. This medical 

examination form is designed to ensure that participants can safely engage in a program’s activities. Any person with normal 

physical and mental capacity can be expected to complete our programs successfully. Please review the participant’s medical history 

and evaluate whether this individual has any conditions that might preclude a successful experience on a rigorous backcountry 

expedition. This exam must happen within one year of the participant’s program start date. 

The FOLLOWING LAB WORK is required by the reSTART INTERNET ADDICTION RECOVERY PROGRAM in addition to the physical 

exam. Please fax results to (425) 222‐7189. 

• Urine Drug Analysis (UDAs) 

• Urine test for possible infection 

• (Females Only) Pregnancy Test with test results indicating positive or negative findings 

• Comprehensive Metabolic Panel 

• Complete Blood Count 

Age:____________ Pulse:____________ 

Height:____________ Blood Pressure:____________ Body Fat % 

Weight:____________ Visual Acuity: Left 20/_______ 

HCT: 

Right 20/_______ 

EST VO2 Max: 

Audiometry: 

Optional 

Normal 

1. Head 

2. Eyes (pupils), ENT 

3. Teeth 

4. Chest 

5. Lungs 

6. Heart 

7. Abdomen 

8. Genitalia 

9. Neurologic 

10. Skin 

11. Physical Maturity 

12. Spine, Back 

13. Shoulders, Upper extremities 

14. Lower extremities 

Abnormal 

Page | 15 



PHYSICAL EXAMINATION (Continued) 


The FOLLOWING CONDITIONS ARE CONTRAINDICATED FOR PARTICIPATION IN THE reSTART INTERNET ADDICTION RECOVERY PROGRAM. Please 

indicate if the following conditions exist: 

Hepatitis A, B or C (if contagious) 

Chicken Pox, Measles, Mumps, Rubella or (other contagious 

agent which would interfere with a group milieu) 

Schizophrenia or mental illness w/psychotic features 

Severe Cognitive Impairments (e.g., Traumatic Brain Injury, IQ < 

90) 

Last date of Tetanus Shot (within past 10 years) ____________________ 

Assessment: 

Full participation 

Limited participation (describe limitations, restrictions): 

________________ ____ 

_______ 

Participation contraindicated (list reasons): 

_________________ 

Recommendations (equipment, taping, rehabilitation, etc.): 

_________________ 

Physician’s Summary 

__________________ 

_____ 

________________ ________ 

PHYSICIAN’S SIGNATURE REQUIRED 

Physician Name: __________________________________________________________________________________ 

Physician Signature: ________________________________________________ Date of exam: ___________________ 

Address: _________________________________________________________________________________________ 

Phone Number: _________________________________ Email Address: _____________________________________ 

Page | 16 



PRESCRIPTION MEDICATION FORM 



1. 

2. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

Medication Dose Directions for use Freq Continue Supply 

Available 

Over the Counter Medications/Vitamins/Herbal Agents/Vaccines 

1. 

2. 

3. 

4. 

5. 

Medication Dose Directions for use Freq Continue Supply 

Available 

Please list any allergies to medications ______________________________________________________________ 

______________________________________________________________________________________________ 

I hereby give permission to reSTART Internet Addiction Recovery program to contact the prescribing physician 

regarding the medications listed on this form. 

Physician _____________________________________________________ _____ Phone ___________________ 

Prescriptions must be called in by a physician in advance. Prescriptions need to be paid in advance using a credit 

card by contacting the pharmacy of choice directly from the list below: 

Albertsons Food and Pharmacy . 3925 236th Ave NE Redmond, WA 98053 (425) 836‐8112 

Quality Food Centers Pharmacy . 4570 Klahanie Dr Se, Issaquah, WA 98075 (425) 392‐2776 

Walgreens . 6300 E Lake Sammamish Pky SE, Issaquah, WA 98027 (425) 369‐0265 

Costco Pharmacy . 1801 10th Ave NW, Issaquah, WA (425) 98027 313‐0965 

Signature of Participant 

Signature of Parent or Caregiver (if under 18) 

__________________________________ 

Date 

__________________________________ 

Date 

Page | 17 




RECOVERY AGREEMENT 

PARTICIPANT 



FINANCIAL SPONSOR 



RATES AND FEE SCHEDULE (Non‐Refundable) 

Rates and Fees Amount* Due Date 

APPLICATION FEE $ 200 With application 

2‐DAY SCREENING INTERVIEW FEE $ 800 Must be received prior to interview date 

AIRPORT PICK‐UP FEE (if needed) $ 200 Must be received prior to interview date 

45‐DAY RETREAT CENTER STAY ($322 per day) $ 14,500 Due upon enrollment 

PARTICIPANT FUND ACCOUNT ($35 per day) 

$ 1,575 Due upon enrollment 

Unused portion (minus $500 stipend to participant‐if 

earned) is refundable at program completion 

PARENT WORKSHOP 

$ 1,000 2‐day workshop ‐ 4 hours per day 

(Optional but recommended) 

Extended Stay Fees 

DAILY RATE $ 325 Due 7 days in advance of completion date 

WEEKLY RATE ($315 PER DAY) $ 2,200 Due 7 days in advance of completion date 

MONTHLY RATE ($300 PER DAY) $ 9,300 Due 7 days in advance of completion date 

PARTICIPANT FUND ACCOUNT ($35 PER DAY) $ tbd Due in advance, prorated based on extended 

stay length (if account drops below $500) 

*Out of state participants will need to submit payment via a cashier’s check as banks hold funds for 2‐3 weeks making it difficult 

to run the program. 

Participant Fund Account: This fund covers extraordinary participant expenses during each 45‐day stay such 

as special clothing for Wilderness Awareness adventures, fishing license, equipment rental, sunscreen, 

additional individualized trainings, medication, personal care, etc. All equipment such as backpacks, sleeping 

bags, tents, etc. is provided. Any equipment damage due to abuse will be billed to participant’s fund 

account. Any remaining funds left in the participant fund account will be returned to the financial sponsor 

upon completion of the program. Statement of fund use will be maintained by the participant as part of the 

life‐skills training and provided to sponsor at session completion. 

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RECOVERY AGREEMENT (continued) 

AGREEMENT 

Average Length of Stay: 45 days 


Start date: _____________________ Anticipated Completion date: ____________________ 

The program is approximately 45 days with the actual length of stay based on how the participant 

progresses through the recovery process. Participants requiring longer stays continue on a weekly or 

monthly tuition basis. All fees for prolonged stays are due in advance within 7 days of the next 

anticipated completion date. Tuition fees are non‐refundable. 

FINANCIAL SPONSOR AGREES TO: 

I ___________________________________________________ (FINANCIAL SPONSOR) acknowledge that I 

have, to my satisfaction, investigated the reSTART Internet Addiction Recovery Program and am fully 

aware of the financial obligations associated with the program, policies, and guidelines and its associated 

risks. I agree to the following: 

• I agree to pay the fees as specified in the rates and fee schedule contained in this agreement. I understand 

that the 45‐day tuition expense of $14,500 covers the cost of food, shelter and daily transportation while 

staying at the Heavensfield Retreat Center. It also covers on‐site individual and group therapy offered by 

reSTART professional staff. Out of state participants will need to submit payment via a cashier’s check as 

banks hold funds for 2‐3 weeks making it difficult to run the program. 

• Additional expenses incurred by reSTART and agreed upon by financial sponsor in advance (when at all 

possible) shall be payable upon receipt. Examples of such expenses may include (but are not limited to) 

specialized nutritional needs, personal healthcare needs with off‐site community providers (e.g., general 

MD practitioners, psychiatrists, nutritionists), and emergency healthcare. 

• I agree to fund to the Participant Account Fund (PAF) in advance at a rate of $1,575 for the 45‐day stay. I 

understand that I will receive a statement prepared by the participant, with an accounting of how the 

funds have been used during the program. I also understand that I will receive any unused portion of the 

PAF funds upon completion of the program. 

• I understand that reSTART program fees are not refundable. I understand that fees will not be refunded 

or pro‐rated if participant is terminated for non‐compliance with program policies by program director, or 

participant voluntarily leaves program before completion date. 

• I agree to pay a late fee of 1.5% per month on all billings not paid in advance with this agreement. If it is 

necessary to refer this Agreement to an attorney for collection, reSTART shall be entitled to its costs and 

reasonable attorney fees. 

Signature of Financial Sponsor 

______ 

________________________ 

Date 

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RECOVERY AGREEMENT (continued) 


PARTICIPANT AGREES TO: 

I ___________________________________________________ (PARTICIPANT) acknowledge that I have, to 

my satisfaction, investigated the reSTART Internet Addiction Recovery Program and am fully aware of the 

obligations associated with the program, policies, and guidelines and its associated risks. I agree to the 

following: 

• I agree to participate in the program to the best of my abilities and to apply the principles learned to 

create a healthier sustainable lifestyle for myself and others who care about me. 

• I understand that I will be terminated from the program for non‐compliance as outlined in the 

student handbook of instructions. I understand that I will be immediately discharged from the 

program for substance use and abuse; or video gaming, gaming or other internet use while in the 

facility. 

• I agree to carry private health insurance and automobile insurance while participating in the reSTART 

Internet Addiction Recovery Program. I will notify reSTART staff if there is a lapse in coverage so that 

alternative plans may be worked out with program providers. 

Signature of Participant 

______ 

________________________ 

Date 

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PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK 

In consideration of the services of reSTART Internet Addiction Recovery Program, Heavensfield, their agents, owners, 

officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf 

(hereinafter collectively referred to as "RESTART"), I hereby agree to release, indemnify, and discharge RESTART, on 

behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows: 

1. I acknowledge that my participation in outdoor adventure based activities such as skiing, bike tours, rock climbing, 

hiking, camping, backpacking, sea kayaking, sailing and fishing entails known and unanticipated risks that could result in 

physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that 

such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. Furthermore, RESTART 

employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a 

participant's fitness or abilities. They might misjudge the weather, the elements, or the terrain. They may give 

inadequate warnings or instructions, and the equipment being used might malfunction. 

2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this 

activity is purely voluntary, and I elect to participate in spite of the risks. 

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless RESTART from any and all 

claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of 

RESTART’s equipment or facilities, including any such claims which allege negligent acts or omissions of RESTART. 

4. Should RESTART or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this 

agreement, I agree to indemnify and hold them harmless for all such fees and costs. 

5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else 

I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any 

medical or physical condition I may have. 

6. In the event that I file a lawsuit against RESTART, I agree to do so solely in the state of Washington, and I further agree 

that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I 

agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in 

full force and effect. 

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this 

activity, I may be found by a court of law to have waived my right to maintain a lawsuit against RESTART on the basis 

of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I 

have read and understood it, and I agree to be bound by its terms. 

Signature of Participant (if over 18) ____________________________________________________________________ 

Print Name _______________________________________________________________________________________ 

Address _________________________________________________________________________________________ 

Phone _______________________ 

Date _______________________ 

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PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK 

PARENT'S OR GUARDIAN'S ADDITIONAL INDEMNIFICATION 

(Must be completed for participants under the age of 18) 

In consideration of (print minor's name)______________________________________________ ("Minor") being 

permitted by RESTART to participate in its activities and to use its equipment and facilities, I further agree to indemnify 

and hold harmless RESTART from any and all Claims which are brought by, or on behalf of Minor, and which are in any 

way connected with such use or participation by Minor. 

Parent or Guardian: ______________________ Print Name: ______________________ Date:___________ 

June 9, 2009 

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SCREENING INTERVIEW PREPARATION FORM 

Step 1: Complete the Application Package and return it to reSTART by mail. Please send a 

digital photo of the applicant to restart@netaddictionrecovery.com. 

Step 2: Your application will be reviewed by the reSTART team for eligibility 

Step 3: Once reviewed and participant is accepted for the screening interview, you will be 

contacted by a member of the team to discuss a screening interview date. 

Step 4: Participant will meet the team of reSTART on site at the Heavensfield Retreat Center 

for a 2‐day screening interview. This allows the applicant to get a feel for the program, meet 

the staff and fellow participants, and for the team to get better acquainted with the applicant. 

Parents and Partners are welcome to visit and tour the facility with the participant. reSTART 

asks that visitors limit their stay to an hour which provides the participant with an opportunity 

to experience the program for themselves. 

Step 5: Upon completion of the 2‐day interview, a determination of fit will be rendered by 

both the applicant and staff. Applicants which are a good match for the program are 

welcome to start their 45‐day program immediately following the screening interview. Full 

tuition is required prior to program start. Tuition fees are non‐refundable once program is 

started. If applicant is not matched for the program, alternate options will be explored and 

provided. 

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WHAT TO BRING TO HEAVENSFIELD RETREAT CENTER (CHECK LIST) 

(This is a GUIDELINE – Participant’s clothing needs may vary - Use your judgment) 

PARTICIPANT’S NAME_____________________________________ SESSION SEASON - W_____S_____S_____ F_____ 

( ) 1 light blanket 

( ) 1 set of twin size sheets 

( ) 1 pillow 

( ) 2 pillow cases 

( ) 1 bath towel 

( ) 1 wash cloth 

( ) 1 pair boots (hiking or outdoor) 

( ) 1 pair casual shoes 

( ) 1 pair tennis shoes 

( ) 1 pair sandals 

( ) 2 pairs pajamas 

( ) 3 pairs blue jeans or long pants 

( ) 1 pair of sweats 

( ) 4 pairs shorts 

( ) 1 bathing suits (camp appropriate) 

( ) 8 T-shirts 

( ) 8 pairs of socks 

( ) 8 pairs underwear 

( ) 1 nice outfit 

Winter/Spring 

( ) Winter Ski Jacket 

( ) Winter Snow Gear (Gloves, Hat, Boots) 

( ) 1 sweatshirt 

( ) 1 jacket (preferably fleece) 

( ) 1 raincoat 

( ) Hat 

( ) Kleenex 

( ) Shampoo 

( ) Toothpaste 

( ) 2 toothbrushes 

( ) 1 pair nail clippers 

( ) 1 flashlight w/batteries 

( ) 1 comb and/or brush 

( ) 1 squeeze bottle of soap 

( ) Personal water bottle 

( ) 

( ) 

Summer/Fall 

( ) Insect repellent (not aerosol, please) 

( ) Sunscreen 

OPTIONAL LIST OF ARTICLES - These items come in handy, but are not absolutely necessary. 

( ) musical instruments (encouraged) 

( ) personal sports equipment 

( ) pictures of loved ones 

( ) 

( ) 

( ) camera 

( ) 1 or 2 good books or magazines 

( ) extra batteries 

( ) Stationary/postcards, stamps 

Remember to send along sufficient toiletry articles for a 45-day stay. This list is not absolute. You may require more or less than what is 

listed. HEAVENSFIELD IS A GOOD PLACE TO WEAR OUT OLD CLOTHES. Please do not bring new clothes or valuables. Laundry 

will be done a minimum of once per week. Plan accordingly. We provide laundry bags. 

NOTE: Personal MP3 players may be brought to Heavensfield. Televisions, game boys, pagers, and computers are NOT allowed. 

Please leave these items at home. Additionally, cellular phones are not allowed at Heavensfield and will be stored in a security 

box while on site. 

MARKING ARTICLES: Mark ALL articles brought to Heavensfield with your name. We have found the “Sharpie” indelible 

permanent marker (may be purchased at Wal-Mart, Target, etc.) to be the easiest, most efficient method to mark items. An accurate list 

of all articles should be made. reSTART IS NOT RESPONSIBLE FOR LOSS OF PERSONAL ARTICLES OR CLOTHING BY THEFT, 

CARELESSNESS OF PARTICIPANT, OR OTHER CAUSES. 

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TRANSPORTATION TO THE RETREAT CENTER 

reSTART Internet Addiction Recovery Program is housed at the Heavensfield Retreat Center which is located 

in Fall City, Washington. The retreat center is approximately 39 minutes from Seattle/Tacoma (SEATAC) 

airport. Transportation to and from SEATAC airport is available for an additional $200 fee. In order to pick up 

participants, please provide flight number, arrival time, and physical description of participant along with a 

photo. 

DIRECTIONS FROM SEATAC AIRPORT 

1: Start out going SOUTH on INTERNATIONAL BLVD/ PACIFIC HWY S/ WA‐99 S. 0.0 mi 

2: Make a U‐TURN onto INTERNATIONAL BLVD/ PACIFIC HWY S/ WA‐99 N. 1.6 mi 

3: Merge onto WA‐518 E toward I‐405/ RENTON/ I‐5. 1.2 mi 

4: Take I‐405 N toward RENTON/ BELLEVUE. 10.8 mi 

5: Merge onto I‐90 E via EXIT 11 toward SPOKANE. 7.2 mi 

6: Take the FRONT ST exit, EXIT 17, toward E LK SAMMAMISH PARKWAY SE. 0.3 mi 

7: Turn SLIGHT LEFT to take the ramp toward E LK SAMMAMISH PARKWAY SE. 0.0 mi 

8: Turn LEFT onto FRONT ST N. 0.2 mi 

9: FRONT ST N becomes E LAKE SAMMAMISH PKWY SE. 0.2 mi 

10: Turn RIGHT onto SE ISSAQUAH‐FALL CITY RD. 3.0 mi 

11: Stay STRAIGHT to go onto SE DUTHIE HILL RD. 2.2 mi 

12: SE DUTHIE HILL RD becomes 292ND AVE SE. 0.1 mi 

13: Turn LEFT onto REDMOND‐FALL CITY RD SE/ WA‐202. 1.0 mi 

14: Turn RIGHT onto SE 8TH ST. 0.4 mi 

15: Turn RIGHT onto 290TH AVE SE (Portions unpaved). 0.1 mi 

16: End at Heavensfield . 1001 ‐ 290th Ave Se Fall City, WA 98024‐7403 

Estimated Time: 39 minutes 

Estimated Distance: 28.34 miles 

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Internet Addiction Recovery Program APPLICATION ... - HEAL

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