PRE-ADMISSION LETTER

Tribal code

Ask Donna

What actually matters in this document.

Text

Dear Applicant:

This letter verifies that you called and completed our phone intake. Please read over the admission

packet that is enclosed, complete and either mail, email, or fax back to Chi Hullo Li. The packet must

be completed using black ink. Please include a copy of your CDIB card or Tribal Membership

verification, social security card, birth certificate, driver’s license, and any other identifying documents.

If you plan to have your child/children with you, there is a two-week waiting period after you are

admitted before your children can be admitted (placement of children may also depend on daycare

availability). Make sure you inform the intake counselor and please include copies of the child’s CDIB

card, birth certificate, social security card, immunization record, and Sooner Care (Medicaid) card. *If

your children will be attending day care (all day or partial day), you will be required to apply for either

Choctaw Nation Childcare Assistance or apply for TANF benefits in order to receive Childcare Subsidy,

or you will be responsible for paying for day care fees. Make sure you discuss this with me prior to

intake.

All the forms enclosed must be signed and dated prior to admission. Each applicant is required to

complete the medical history form enclosed. All current medications (including prescription and over

the counter) must be listed. Please note that a TB Test must be current.

After the admission packet is returned to Chi Hullo Li and is properly completed, and all documents

are received, you will be placed on our waiting list. (Please call me when you mail or fax any

information to Chi Hullo Li.) After being placed on the waiting list, you are encouraged to maintain

regular contact with the intake counselor—every week.

Chi Hullo Li is a long-term treatment program—length is a minimum of 3 months. All clients are

provisionally admitted for the first 30 days. During these first 30 days, if it is found that Chi Hullo Li is

not the appropriate form of treatment for the client, treatment can be terminated, or the client may be

referred to another facility.

Choctaw Nation-Chi Hullo Li Residential Treatment Center has established specific criteria for

acceptance into this program. Our program is based on a holistic approach with emphasis on the healing

of mind, spirit, and body. Our program is not designed as a medical detox facility; therefore, we

cannot admit a client in need of detoxification services. All clients must complete a physical at the

Choctaw Nation Health Care facility in Talihina at admission.

If you have any questions, please contact me at 888-449-2905 or 918-567-2905 or email me at

mlfry@cnhsa.com

Thank you,

Michelle Fry, LPN

Intake Counselor

(YOU CAN KEEP THIS PAGE—WE DO NOT NEED THIS PAGE BACK!)

Excellence In Rural Health Care

Revised 03/25/24 AB

PRE-ADMISSION

CHECKLIST

PLEASE MAKE SURE YOU SUBMIT ALL OF THE FOLLOWING INFORMATION:

INFORMED CONSENT FOR PLACEMENT (pg. 3)—read, sign, and return

RELEASE OF INFORMATION (pg. 4)—complete, sign, and return

INFORMED CONSENT FOR CHILDREN AND DAYCARE (pg. 5)—read, sign, and return

ADULT MEDICAL HISTORY FORM (pg. 6-7)—complete and return

COPY OF TB TEST RESULTS WITH LOCATION

PERSONAL BELONGINGS LIST (pg. 8-9)—read, sign, and return (pg. 10-11 is your copy to keep)

COPY OF APPLICANT’S CDIB/TRIBAL MEMBERSHIP (must be readable—better to email)

COPY OF APPLICANT’S SOCIAL SECURITY CARD, BIRTH CERTIFICATE, DRIVER’S

LICENSE/STATE ID (IF AVAILABLE) (must be readable— it is better to email it)

CHILD MEDICAL HISTORY FORM (pg. 14-15)—if you have children that will be residents, you

will need to complete and return along with any of your children’s identifying documents

*IDENTIFYING DOCUMENTS ARE NOT ALWAYS READABLE WHEN FAXED, IT IS

BETTER IF YOU EMAIL THEM TO mlfry@cnhsa.com

**YOU MUST BE ON TIME FOR INTAKE—IF YOU ARE MORE THAN 30

MINUTES LATE, YOU WILL NOT BE ADMITTED!

Revised 03/25/24 AB

PRE-ADMISSION INFORMED CONSENT FOR PLACEMENT

Chi Hullo Li, its employees, affiliates, consultants, and physicians are authorized to review any and all

information contained in the application packet to determine the appropriateness of the applicant’s

placement at this residential treatment facility.

Upon being admitted, I understand that I will undergo a body search and a search of my personal

belongings will be conducted and if any drugs or paraphernalia is found Tribal Police will be notified.

I understand that I will attend an intake physical at admittance and must be medically cleared to be fully

admitted into the program.

I understand that once I am scheduled for intake if I am more than 30 minutes late for my intake

appointment that I will not be admitted.

I understand that my records are protected under both Federal Law 42 CFR, part two, and state

confidentiality laws and regulations. They cannot be released without my written consent unless

otherwise provided within said laws and regulations. Federal regulations prohibit any further disclosure

of the specified information without specific written consent of the person to whom it pertains, or as

otherwise permitted by such laws and regulation. I also understand that I may revoke this consent in

writing, at any time, unless action has already been taken based upon it. Moreover, that in any event,

this consent expires automatically upon admission into the program, unless another date is specified.

The information authorized for release may include records, which might indicate the presence of a

communicable, or venereal diseases, which could include, but not limited to diseases such as hepatitis,

syphilis, gonorrhea, and the Human Immunodeficiency Virus (HIV), or Acquired Immune Deficiency

Syndrome (AIDS).

___________________________________________

Applicant’s signature

Revised 03/25/24 AB

__________________

Date

____________

Time

(SIGN AND RETURN THIS PAGE—WE NEED THIS PAGE BACK!)

PRE-ADMISSION RELEASE OF INFORMATION

*If you would like someone to be able to call to confirm information or check the status of your

application, you must list them on this form, or we will not be able to release any information.

I, ________________________________________________, am authorizing the release of

Name of Applicant

information regarding: waiting list status, scheduling for admission, and/or eligibility for

treatment. I am authorizing Chi Hullo Li Residential Treatment Center, whose address is 13597

SE 202nd Road Talihina, OK 74571, to release this information to the following sources (complete

all that apply):

DHS- List County, name of worker, and phone number:

_________________________________________________________________________________

ICW-List Tribe, name of worker, and phone number:

_________________________________________________________________________________

Probation/Parole Officer, List whether State or Tribal, name, and phone number:

_________________________________________________________________________________

D.A. or Assistant D.A.- List county, name, and phone number:

_________________________________________________________________________________

Lawyer or Attorney- List name and phone number:

_________________________________________________________________________________

Court, Judge, Court Clerk- List County, name, and phone number:

_________________________________________________________________________________

Tribal Court, Judge, Court Clerk- List Tribe, name, and phone number:

_________________________________________________________________________________

Other: List name, title, and phone number:

_________________________________________________________________________________

Or (Please Check)

_________ No Releases at this time.

I understand that my records are protected under the Federal regulations governing Confidentiality of

Alcohol and Drug Abuse Patient Records, 42CFR Part 2, and cannot be disclosed without my written consent

unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time

except to the extent that action has been taken in reliance on it, and that in any event, this consent expires

automatically as follows: (upon admission, or specify the date, event, or condition upon which this consent

will expire.)___________________________________________________________

___________________________________________

Applicant’s signature

Revised 03/25/24 AB

__________________

Date

____________

Time

(SIGN, COMPLETE, AND RETURN THIS PAGE—WE NEED THIS PAGE BACK!)

PRE-ADMISSION INFORMED CONSENT

FOR CHILDREN AND DAY CARE

All applicants must read and sign this document.

If clients plan to have their child/children reside with them at Chi Hullo Li, there is a two-week waiting

period after clients are admitted before their children can be admitted. Placement of children may also

depend on daycare availability.

All children between the ages of 6 weeks old and 6 years old, must attend day care during clinical hours

and the day care fees must be paid.

Clients have three options regarding paying for daycare: Option 1) Client must apply for Choctaw

Nation Child Care Assistance; Option 2) Client must apply for and be eligible for TANF benefits

through the Leflore/Latimer DHS office (DHS will pursue the father for child support)—if the client is

eligible for TANF she will also be eligible for DHS Child Care Subsidy which will pay for day care; or

Option 3) Client will be responsible for paying for day care fees out of her own pocket, which is

approximately $25.00 per child per day.

Children ages 6-11 will attend school and Choctaw Nation Youth Center.

Make sure you discuss this with the Intake Counselor prior to intake.

I have read the above information and understand and agree to these guidelines.

By signing this form, I am authorizing the release of information regarding mine and my

child/children’s waiting list status, scheduling for admission, and/or eligibility for treatment to the

Choctaw Nation Day Care in Talihina and/or Cindy Clingan’s Day Care in Talihina and/or Oh

the Places You Can Go Childcare LLC in Talihina for the purpose of applying for daycare

services.

___________________________________________

Applicant’s signature

Revised 03/25/24 AB

__________________

Date

____________

Time

(SIGN AND RETURN THIS PAGE—WE NEED THIS PAGE BACK!)

PRE-ADMISSION

ADULT MEDICAL HISTORY FORM

Our facility is a residential living unit, and we need to be aware of any communicable diseases that an

individual might have, which could be detrimental to other residents or staff members. Therefore, each

applicant must fully complete this form.

The applicant must complete all sections (I, II, III, and IV).

List all prescription medication that you are currently taking.

List any over-the-counter medications that you are currently taking.

You must include a copy of your current TB Test/PPD results from the agency or health clinic

from which it was administered and read (must be within the last year). The nurse or provider

reading the PPD skin test must sign the form. If your PPD skin test is positive, you will be

required to have a chest x-ray and you will need to send those results also.

Applicant Identification:

__________________________________________________

Name (Last, First, and Middle Initial)

_______________________

Date

_________________________________________________________________________________

Address

City

State

Zip Code

_______________________

Date of Birth

____________________________________

Social Security Number

Primary Drug of Choice: ___________________________________________

Secondary Drug of Choice: __________________________________________

II.

Medical History (Relevant History):

_________________________________________________________________________________

Revised 03/25/24 AB

III.

You must list any prescription medications that you are currently taking. Do not bring your

medications with you. Medications that are brought in will be disposed of. It is very

important that you provide this information, so that you can obtain new prescriptions at

Choctaw Nation Health Care Center in Talihina during your intake physical on the day of

admission.

Name of Medication

IV.

Dosage

Frequency

Route of

Administration

List any over-the-counter medications that you are currently taking (including eye-drops,

creams, vitamins, etc.):

_________________________________________________________________________________

**YOU MUST INCLUDE A COPY OF YOUR CURRENT TB TEST/PPD RESULTS FROM

THE AGENCY OR HEALTH CLINIC FROM WHICH IT WAS ADMINISTERED AND READ

(must be within the last year).

(COMPLETE AND RETURN PAGES 6 &7—WE NEED THESE PAGES BACK!)

Revised 03/25/24 AB

Personal Belongings List

(Please sign this form and send back)

All belongings MUST be packed in trash bags and/or zip lock bags.

**NO SUITCASES, NO TOTE BAGS, NO BACKPACKS, NO

COSMETIC BAGS, ETC.**

What you need to bring for yourself:

1 purse and/or 1 wallet

ONLY 1 trash bag of clothes (up to 30-gallon size trash

Feminine products

bag)

Shoes-up to 5 pair

Up to 4 towels;

Washcloths

Toothbrush and

toothpaste (no mouthwash

of any kind)

List of current medications

Soap, shampoo, conditioner, hairbrush/comb, razor,

deodorant

Postage stamps and envelopes

Photo ID, State ID,

or Driver’s License

Clothes hangers

Appropriate clothing (None of the following clothing

is allowed: halter or spaghetti strap tops, baremidriff blouses, short shorts/skirts, see-through or

extremely tight clothing, clothing promoting the use

of alcohol, tobacco, or other drugs)

Undergarments (bras and underwear)

Calling cards- IDT US

Minutes from Dollar

General is

recommended

You (and your children’s) social security cards/birth

certificates, if you plan on applying for housing or

other programs (copies are sufficient)

House Shoes (with

protective soles)

Sleepwear

(just a list-not the medications)

Any important phone

numbers you may need;

Usernames and passwords

Other items you may bring if you wish:

Alarm clock

Small stereo/radio and

CDs

Ear buds/Headphones

Hair products (only

allowed 1 gallon size zip

lock bag)

Make-up and face wash

(only allowed 1 gallon

size zip lock bag)

Perfume (up to 3)

Hair dryer,

straightening/curling iron

Revised 03/25/24 AB

You may bring cigarettes, but they must be in

unopened packages and disposable lighters only

Nail polish, polish remover, non-metal nail file,

nail clippers, tweezers

MP3 player—can’t be internet capable or take or

play digital photos

Craft supplies (only what will fit in 1-gallon zip

lock bag) (beads must be new in unopened pkg)

Other items will be allowed at the discretion of

staff

HE Detergent and/or fabric softener, dryer sheets

(we provide detergent, but you can bring your

own as long as it is HE and fits in the lockers we

provide); No chlorine bleach—Only non-chlorine

Canned or bottled pop/juice (no 2 liters and no

glass containers)

Solid, non-aerosol, & non-plug-in air freshener

(none of the following types of air fresheners: no

aerosol, no liquid; no plug in; no stick-on; no gel

beads)

Up to 5 books

Lotion/moisturiz

er and

sunscreen

Jewelry (1 zip

lock bag)

Shaving cream

1 Seat cushion

for chair

1 small

handheld mirror

1 Laundry

Basket or dirty

laundry bag

1 Shower Caddy to carry

Hard individually wrapped candy (no chocolate)

A Robe

Microwave popcorn or

microwave pork-rinds

A few photos or 1 small

photo album (no picture

frames)

Usernames and

Passwords

A few nicer/dressier clothes for special events

A swimsuit for summer outings

Paper, notebook, pens, pencils, highlighters (NO

MORE THAN 1 GALLON BAG OF

PENS/PENCILS/MARKERS)

1 regular binder for classes/homework

Cash/debit/cred

it card

Small/medium

fan-must be

new in box

1 Night Light

Apply for CashApp or something similar

DO NOT BRING ANY OF THE FOLLOWING, THESE ITEMS ARE NOT ALLOWED:

*Vapes/Electronic Cigarettes; *Cell phones; *Medications or anything that is labeled

Medicated; *Anti-bacterial hand gel/Hand sanitizer; *Chap stick of any kind; *Bags of

any kind unless listed above; *Sheets/bedding/blankets/pillows (except for blankets

allowed for children); *Devices that take or play digital pictures, videos, text, or are

internet capable; *Mouthwash of any kind; *Weapons of any kind; *Insect repellant;

*Chlorine bleach; *Liquid starch; *Fabric freshener (like Febreze); *Cleaning products; *

Air freshener in the form of aerosol/liquid/gel beads; *Personal DVD players/TVs;

*Video game systems.

IF IT IS NOT ON THIS LIST—DO NOT BRING IT! All items are subject to staff’s approval.

**MAXIMUM AMOUNT OF ITEMS MUST FIT IN ONE 30 GALLON TRASH BAG

AND ONE 13 GALLON TRASH BAG OR IN YOUR LAUNDRY BASKET (WITH

THE EXCEPTION OF DETERGENT AND POP). PUT ALL CLOTHES AND SHOES

IN THE 30 GALLON TRASHBAG THEN YOU CAN PUT YOUR OTHER

PERSONAL ITEMS IN THE 13 GALLON TRASH BAG OR IN YOUR LAUNDRY

BASKET IF YOU HAVE ONE.

ALL ITEMS BROUGHT IN WILL BE SEARCHED BY STAFF AT ADMISSION. IT IS

IMPORTANT TO ADHERE TO THE ITEMS LIST. IF YOU BRING MORE THAN

ALLOWED, IT MAY BE DISPOSED OF.

My signature below, indicates that I understand that anything I bring that is not on this list will be

discarded or disposed of and that if any drugs or drug paraphernalia is found in my belongings that

Tribal Police will be notified.

___________________________________________

Applicant’s signature

__________________

Date

(SIGN AND RETURN PAGES 8 & 9—WE NEED THESE PAGES BACK!)

Revised 03/25/24 AB

____________

Time

Personal Belongings List

(You keep pages 10-11)