Internet Addiction Recovery Program APPLICATION ... - HEAL

Internet Addiction Recovery Program
RECOVERY AGREEMENT
PARTICIPANT
LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME PERSONAL ID#(PID) *SOCIAL SECURITY NUMBER
PERMANENT ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER
FINANCIAL SPONSOR
LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME PERSONAL ID#(PID) *SOCIAL SECURITY NUMBER
PERMANENT ADDRESS CITY STATE ZIP CODE AREA CODE/PHONE NUMBER
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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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