Internet Addiction Recovery Program APPLICATION ... - HEAL

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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. Page | 18 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
RECOVERY AGREEMENT (continued) AGREEMENT Average Length of Stay: 45 days Internet Addiction Recovery Program 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 Page | 19 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
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Internet Addiction Recovery Program APPLICATION ... - HEAL

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