This contract represents another way to structure the home experience for the recovering teenager coming out of a drug rehab. Caron was happy to let us publish this here. You can learn more about Caron Foundation at http://www.caron.org/.
Caron Adolescent Treatment Center
Home Contract
Patient Name:_________________ Date:______________ Patient #:__________
Mother:_______________________ Step-Mother: ____________________________
Father: _______________________ Step-Father: ____________________________
Siblings: ______________________________________________________________
Siblings: ______________________________________________________________
This is a three-month Home Contract that is intended to provide structure, consistency and boundaries that any family needs at this time in recovery. It is between the patient and his or her family. It can be changed only when all who are involved are present and can agree on the changes.
Basic Rules
This section outlines the bottom line rules that are to be followed by all patients upon discharge.
1. Mutual respect between family members (includes Honesty, Openness and Willingness to listen to each other.)
2. Attendance is required for all aftercare appointments.
3. Other family members agree not to abuse chemicals (specifically parents)
4. Active and regular participation in a 12-Step Fellowship, finding a sponsor within 14 days and attending at least ___ meetings per week.
5. No new relationships
People, Places and Things
The next session outlines the People, Places and Things that the patient feels may be problematic for his/her early recovery. It also outlines some of the more supportive aspects of their environment.
People Who may NEGATIVELY influence recovery and/or attitudes are:
1. ______________________ 6. _______________________ 11. _________________
2. ______________________ 7. _______________________ 12. _________________
3. ______________________ 8. _______________________ 13. _________________
4. ______________________ 9. _______________________ 14. _________________
5. ______________________10._______________________ 15. _________________
People who may be able to support recovery and healthy attitudes are:
1. ______________________ 6. _______________________ 11. _________________
2. ______________________ 7. _______________________ 12. _________________
3. ______________________ 8. _______________________ 13. _________________
4. ______________________ 9. _______________________ 14. _________________
5. ______________________10._______________________ 15. _________________
Places where my recovery could be put in danger or negatively influenced are:
1. ______________________ 6. _______________________ 11. _________________
2. ______________________ 7. _______________________ 12. _________________
3. ______________________ 8. _______________________ 13. _________________
4. ______________________ 9. _______________________ 14. _________________
5. ______________________10._______________________ 15. _________________
Places where I can gain support and positive direction are:
1. ______________________ 6. _______________________ 11. _________________
2. ______________________ 7. _______________________ 12. _________________
3. ______________________ 8. _______________________ 13. _________________
4. ______________________ 9. _______________________ 14. _________________
5. ______________________10._______________________ 15. _________________
Things are attitudes, behaviors and patterns that effect recovery. The things I need to change are:
Behaviors: I will follow the following curfew times:
During the Week
· In the House by ________p.m.
· Wake up by _________ a.m.
On the Weekend
· In the house by __________p.m.
· Wake up by __________ a.m.
I will help out in the house by doing the following chores:
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
We will begin to change the patterns within our family by holding one family meeting per week at which time we will attempt to share openly and honestly. This is a time to confront attitudes, problems, share feelings and take family inventory.
Day _______________________________ Time ___________________
I will also be changing my patterns for when I do go out.
When I go out I will:
1. Make sure it is okay with my parents.
2. Let them know exactly Where I am going to be.
3. Let them know Who I am going to be with.
4. Let them know When I plan on getting back.
5. Call if my plans change at all while I am out.
6. Discuss any major upcoming events well in advance.
In an attempt to increase the level of accountability, the following consequences will occur when I fail to uphold this Home Contract. The first set of consequences is for non-chemical violations (such as doing chores, skipping out of responsibilities, etc.), the second set of consequences is for major violations, primarily chemical use but could include running away and other addictive behaviors.
When I fail to meet my basic responsibilities, I will accept the following consequences:
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4. ____________________________________________________________________
If I use chemicals, there may be two Scenarios. If I am able to be up front and honest about a relapse, I will call my sponsor, call my counselor, share my experience with my aftercare group and my family. I will also accept the following consequences:
1. ____________________________________________________________________
2. ____________________________________________________________________
If I use chemicals and need to be confronted about it, or if I continue to display addictive attitudes, avoidance and defiance, I will have a family session with my aftercare counselor and accept the following consequences:
1. ____________________________________________________________________
2. ____________________________________________________________________
I have helped write this contract and feel that I will be able to follow the guidelines that are written in it.
Patient Signature Parent Signature
Parent Signature Therapist Signature
Date
Caron Adolescent Treatment Center
Home Contract
Patient Name:_________________ Date:______________ Patient #:__________
Mother:_______________________ Step-Mother: ____________________________
Father: _______________________ Step-Father: ____________________________
Siblings: ______________________________________________________________
Siblings: ______________________________________________________________
This is a three-month Home Contract that is intended to provide structure, consistency and boundaries that any family needs at this time in recovery. It is between the patient and his or her family. It can be changed only when all who are involved are present and can agree on the changes.
Basic Rules
This section outlines the bottom line rules that are to be followed by all patients upon discharge.
1. Mutual respect between family members (includes Honesty, Openness and Willingness to listen to each other.)
2. Attendance is required for all aftercare appointments.
3. Other family members agree not to abuse chemicals (specifically parents)
4. Active and regular participation in a 12-Step Fellowship, finding a sponsor within 14 days and attending at least ___ meetings per week.
5. No new relationships
People, Places and Things
The next session outlines the People, Places and Things that the patient feels may be problematic for his/her early recovery. It also outlines some of the more supportive aspects of their environment.
People Who may NEGATIVELY influence recovery and/or attitudes are:
1. ______________________ 6. _______________________ 11. _________________
2. ______________________ 7. _______________________ 12. _________________
3. ______________________ 8. _______________________ 13. _________________
4. ______________________ 9. _______________________ 14. _________________
5. ______________________10._______________________ 15. _________________
People who may be able to support recovery and healthy attitudes are:
1. ______________________ 6. _______________________ 11. _________________
2. ______________________ 7. _______________________ 12. _________________
3. ______________________ 8. _______________________ 13. _________________
4. ______________________ 9. _______________________ 14. _________________
5. ______________________10._______________________ 15. _________________
Places where my recovery could be put in danger or negatively influenced are:
1. ______________________ 6. _______________________ 11. _________________
2. ______________________ 7. _______________________ 12. _________________
3. ______________________ 8. _______________________ 13. _________________
4. ______________________ 9. _______________________ 14. _________________
5. ______________________10._______________________ 15. _________________
Places where I can gain support and positive direction are:
1. ______________________ 6. _______________________ 11. _________________
2. ______________________ 7. _______________________ 12. _________________
3. ______________________ 8. _______________________ 13. _________________
4. ______________________ 9. _______________________ 14. _________________
5. ______________________10._______________________ 15. _________________
Things are attitudes, behaviors and patterns that effect recovery. The things I need to change are:
Behaviors: I will follow the following curfew times:
During the Week
· In the House by ________p.m.
· Wake up by _________ a.m.
On the Weekend
· In the house by __________p.m.
· Wake up by __________ a.m.
I will help out in the house by doing the following chores:
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
_________________________ ________ Daily _______Weekly _____ As Needed
We will begin to change the patterns within our family by holding one family meeting per week at which time we will attempt to share openly and honestly. This is a time to confront attitudes, problems, share feelings and take family inventory.
Day _______________________________ Time ___________________
I will also be changing my patterns for when I do go out.
When I go out I will:
1. Make sure it is okay with my parents.
2. Let them know exactly Where I am going to be.
3. Let them know Who I am going to be with.
4. Let them know When I plan on getting back.
5. Call if my plans change at all while I am out.
6. Discuss any major upcoming events well in advance.
In an attempt to increase the level of accountability, the following consequences will occur when I fail to uphold this Home Contract. The first set of consequences is for non-chemical violations (such as doing chores, skipping out of responsibilities, etc.), the second set of consequences is for major violations, primarily chemical use but could include running away and other addictive behaviors.
When I fail to meet my basic responsibilities, I will accept the following consequences:
1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4. ____________________________________________________________________
If I use chemicals, there may be two Scenarios. If I am able to be up front and honest about a relapse, I will call my sponsor, call my counselor, share my experience with my aftercare group and my family. I will also accept the following consequences:
1. ____________________________________________________________________
2. ____________________________________________________________________
If I use chemicals and need to be confronted about it, or if I continue to display addictive attitudes, avoidance and defiance, I will have a family session with my aftercare counselor and accept the following consequences:
1. ____________________________________________________________________
2. ____________________________________________________________________
I have helped write this contract and feel that I will be able to follow the guidelines that are written in it.
Patient Signature Parent Signature
Parent Signature Therapist Signature
Date
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