Cirque Lodge Resident Admission Agreement

Resident Identification


Resident Name:
Date of Birth:
Marital Status:
Mailing Address:
Home Phone:
Cell Phone:
Work Phone:
Email Address:


Health Insurance Company Name:
Group Number:
ID Number:
PCN Number:
BIN Number:


Does resident appear on the national database?

Confidentiality Agreement

I understand that I have a duty to maintain the confidentiality of all persons residing in Cirque Lodge. I also agree that I have a responsibility to respect the need for confidentiality around information that is revealed by other residents in groups or personal conversations. This confidentiality means that I will not reveal names of other residents, resident’s family members or any information they reveal to me. That includes my family, friends and others. I ask my peers to have the same obligations to respect my right to confidentiality. I understand that I am subject to discharge if I violate this agreement while a resident at Cirque Lodge I acknowledge that I have understood the Summary of Federal Regulations regarding confidentiality of alcohol and drug abuse patient records. Further, I understand that for my protection and the protection of other Residents, warranted, unannounced searches for contraband may be made.

Signed By: on date:

Conditions of Admission

The undersigned does hereby apply for admission as a resident of Cirque Lodge. By accepting the resident at the facility, Cirque Lodge does not warrant or agree to effect a cure but does agree to accord the resident such medical care and treatment for alcoholism and/or addiction as will provide him/her the maximum opportunity for recovery. The practice of medicine and the treatment of addiction are not exact sciences, and no guarantee can be made to the results of the treatment. The following conditions and provisions shall govern the treatment, care and accommodations provided to all residents at the facility. Only the Board of Directors can modify, change or revise any of these conditions and provisions. The undersigned hereby applies for admission as a resident of Cirque Lodge. Cirque Lodge does not promise or agree to effect a cure but does agree to accord the resident such treatment for alcoholism and/or addiction as will provide resident the maximum opportunity for recovery. The practice of medicine and the treatment of addiction are not exact sciences and no guarantee can be made as to the results of the treatment. The following conditions and provisions shall govern the treatment, care and accommodations provided to all residents at Cirque Lodge. The resident agrees to conform to the rules and regulations of Cirque Lodge.

  • DEPOSIT: The deposit upon admissions has been agreed upon for a program of treatment designed to effect the rehabilitation of the resident. This deposit will be applied to total costs incurred by the resident while at Cirque Lodge and is listed separated on the payment agreement.
  • MEDICAL: Any person requiring special nursing care, non-routine medication, psychiatric or psychological consultation, or medical services not normally provided by Cirque Lodge will be responsible for payment of such care to the administering party. The selection of care givers will be made by Cirque Lodge, but insofar as possible, the requests of the resident will be respected.
  • TERMINATION: The status of any resident may be terminated whenever Cirque Lodge determines that the resident has failed, neglected, or refused to cooperate with the staff in its efforts to treat such resident.
  • DISCHARGE: In the event that the resident requests discharge against staff advice, Cirque Lodge requires a twenty-four (24) hour notice from the resident. The purpose of this policy is to allow for continuing care and discharge planning to be implemented prior to discharge. Any outstanding balance must also be paid prior to discharge.
  • GRIEVANCE PROCEDURE: The resident acknowledges that the resident has been informed of and understands the Cirque Lodge resident grievance procedure.
  • CONSENT TO CARE AND TREATMENT: By accepting these Conditions of Admission, the resident consents to such medical care and treatment as deemed necessary or helpful by Cirque Lodge personnel in their efforts to effect rehabilitation.
  • CONSENT TO SEARCH: The resident authorizes Cirque Lodge personnel, at any time, to conduct a thorough search of the resident’s room and personal property, and, if necessary, of the resident’s person, for any illegal or controlled substances or contraband. The resident further authorizes Cirque Lodge personnel to destroy any confiscated items.
  • INSURANCE/FINANCIAL: The undersigned agrees, whether he or she signs as the resident or an agent, that in consideration of the admission of the resident to Cirque Lodge and of the services to be rendered to the resident, he or she hereby individually obligates himself or herself to pay the account of Cirque Lodge in accordance with the regular rates and terms of Cirque Lodge. The undersigned hereby authorizes payment directly to Cirque Lodge of the benefits otherwise payable to him or her for the hospitalization of the resident, and understands that he or she is financially responsible to Cirque Lodge for all charges not covered by this assignment, and hereby assumes full responsibility for their payment. Should the account be referred to collections or an attorney, the undersigned shall pay actual collection expenses and attorney’s fees. Delinquent accounts shall bear interest at the rate of twenty-one (21%) per annum.
  • DAMAGE: Any damage to Cirque Lodge property caused by the resident will be billed to the resident’s account at the actual cost of repair or replacement.
  • DISPUTE RESOLUTION: The resident agrees that any dispute with Cirque Lodge shall be first submitted to mediation through a mediator mutually agreed upon by the resident and Cirque Lodge. Each party will bear its own cost of mediation. If mediation fails, the resident and Cirque Lodge shall submit the dispute to binding arbitration in Utah County pursuant to the provisions of the Utah Uniform Arbitration Act, and the prevailing party shall be entitled to costs and reasonable attorney’s fees. The resident expressly waives all rights to pursue any legal action to seek damages or any other remedies in a court of law, except to enforce the agreement to arbitrate, to collect an arbitration award, and to facilitate the arbitration process.

The undersigned accepts the terms hereof, certifies that he/she has read the foregoing, has received a copy hereof, and is the resident, or is authorized to sign as resident’s agent.


Signed By: on date:

Behavioral Agreement

BEHAVIOR THAT CAN RESULT IN EARLY DISCHARGE OR TRANSFER FROM CIRQUE LODGE: Our goal at Cirque Lodge is for you to have a successful treatment experience. We need to inform you that there are behaviors that could interfere with your recovery and might result in discharge or transfer and forfeiture of monies on deposit. We ask that you read and understand what those inappropriate behaviors are. We encourage your questions. We want to ensure that all residents are provided with a safe environment that is conducive to recovery.

The following list of behaviors may lead to discharge or transfer to another facility:

  • The use or supplying of mood altering drugs or illegal substances.
  • Noncompliance with medical care and/or clinical treatment recommendations and/or not meeting program expectations or requirements.
  • Fraternizing; sexual contact with another resident and/or staff member.
  • Any violent behavior. This includes explosive outbursts, hitting, slapping, kicking, verbal threats, intimidation or property damage.
  • Stealing
  • Leaving Cirque Lodge campus without staff knowledge and permission.

I have reviewed the list of inappropriate behaviors, and I understand and agree that if l behave inappropriately, I may be discharged or transferred, and will forfeit any monies paid to Cirque Lodge.

Signed By: on date:

Experiential Participant Release

Cirque Lodge programs involve a variety of activities that often include warm-ups, games, and group initiative problems and low and high ropes course elements. The level of participation in a program activity is at all times completely up to the participant that he/she may suffer an emotional or physical injury, disability or death. Every participant in Cirque Lodge programs is required to have health/accident insurance coverage. In addition, certain health/medical information must be made known to the instructor(s) conducting the programs so that they are prepared to respond appropriately if the need arises. This information will be held in confidence.

Do you have any limiting physical or mental disabilities or medical restrictions (temporary or permanent) that could present a hazard to yourself or others during the duration of this program?

If yes, identify and explain:


I understand that parts of the Cirque Lodge program may be physically or emotionally demanding. I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate in activities. I understand that each participant must assume the risk of physical injury that could result from any of these activities. I release Cirque Lodge, and its staff members, from all liability for any injury to me from participation in Cirque Lodge activities. I understand that these terms shall serve as a release of liability for my heirs, executors, administrators and for members of my family. I have carefully read this Disclosure and Release of Liability and fully understand its content.

Signed By: on date:

Insurance Admission

Cirque Lodge is not responsible to verify insurance coverage, pre-certify, or give any indication of benefits that may or may not be available for residential care. Verification of coverage and pre-certification is the responsibility of the resident and should be done prior to the resident’s admission. Upon written request Cirque Lodge will provide residents with a copy of their billing statement. Cirque Lodge does not guarantee any payment in any amount by a resident’s insurance provider.

I agree that upon discharge, unless otherwise directed in writing, Cirque Lodge may bill my insurance company for Cirque Lodge’s usual and customary fees. I understand that billing my insurance company is not a guarantee of payment.

If my insurance provider reimburses me for my treatment at Cirque Lodge, I agree that I am not entitled to keep any money until Cirque Lodge has been reimbursed for its entire usual and customary fees. If my insurance provider sends any payment directly to me for my treatment at Cirque Lodge, I will endorse and deliver such payment to Cirque Lodge immediately upon receipt.

I agree, that upon discharge, Cirque Lodge may bill my insurance company for total charges including but not limited to Cirque Lodge’s usual and customary fees. I understand that billing my insurance is NOT a guarantee of payment. Upon written request Cirque Lodge will provide me with a copy of my billing statement.

Signed By: on date:

Protected Health Information Notice of Privacy Practice with Harmon’s Pharmacy & Medication Policy and Procedure Notice

I have read and understand the Protected Health Information (PHI) Notice of Privacy Practice. I agree and authorize Cirque Lodge Staff to sign for and transfer any medications from Harmon’s Pharmacy. I understand that if I do not authorize Cirque Lodge staff to order medications prescribed that I may be discharged from the Cirque Lodge Treatment Program. I understand that Cirque Lodge must acquire all medications through a known, trusted, and local pharmacy. As such, once I have met with the Medical Director, any medications prescribed for me must be ordered through one of these pharmacies and any medications brought from home will be mailed home at that time. I have read and understand the Protected Health Information (PHI) Notice of Privacy Practice. Further, I agree and authorize Cirque Lodge to contact and schedule medical appointments as needed, to be in compliance with JCAHO and Utah State Law.

Signed By: on date:

Consent for Release of Confidential Information to the Identified Emergency Contact

I authorize Cirque Lodge to release information regarding emergencies and/or changes in my status to:

Emergency Contact, who is resident’s

Home Phone:

Cell Phone:


I understand that I may revoke this consent for release of information at any time; however, I also understand that any release which has been made prior to my revocation and which was made in reliance upon this authorization shall not constitute a breach of right to confidentiality. If no date of revocation is specified, this consent shall expire ninety (90) days from the date of signature below. I certify that this request has been made freely, voluntarily and without coercion.

Signed By: on date:

Personal Belongings & 72 Hour Communication Policy

I acknowledge that Cirque Lodge has the right to search my belongings at any time for illicit or contraband items as determined by the program with or without prior notification or my presence. Cirque Lodge is not responsible for replacement of stolen or damaged property, valuables, money, credit/debit cards or checks.

Cirque Lodge will keep up to $500.00 cash in the safe on site. It is advised that any other valuables not kept on my person 24 hours a day should be sent home. If I choose to keep these items here I am personally taking responsibility for them should anything happen to them. By signing, I am acknowledging that I understand the personal belongings and safe policy and do not hold Cirque Lodge responsible for any of my personal belongings.

Safe Hours:
Monday – Friday 11:30 am to 5:30 pm

I have also received my Resident ID Number and was allowed a phone call to advise my family that I arrived and that there is a 72 hour communication blackout. I will be allowed normal phone use within standards of the program once the blackout is lifted. I acknowledge that regular computer use is not allowed outside of times set aside with my counselor until I reach the appropriate level within the program to use a computer alone. Further, I acknowledge that use of any personal laptops, tablets, or cell phones is generally prohibited even if I attain advanced level status. If brought in to the facility and I choose to not send them home, these items will be kept in a secure room open only to staff. As noted above, I acknowledge that Cirque Lodge is not responsible for replacement of damaged property I have chosen to keep here but which must be secured out of my possession.

Signed By: on date:

Release of Liability

THIS IS A LEGALLY BINDING AGREEMENT. In consideration of my being accepted to participate in the therapeutic program offered by Cirque Lodge, including but not limited to its program activities, I agree to the following waiver and release and make the following representations:

  • It has been explained to me that the treatment program at Cirque Lodge includes games, group initiative problems, exercise, weight lifting, hiking, climbing, rope courses, equine contact and therapy, vehicular travel, possible use of watercraft and aircraft, and other activities which involve a certain amount of risk and inherent danger. I acknowledge the inherent risk in these activities, including but not limited to, use of facilities such as saunas, accidents, falls, unexpected contact with walls or equipment, misuse or failure of equipment, errors of other participants, animals, mountainous terrain, adverse weather, winter conditions, dehydration, and other events which cannot be foreseen. I acknowledge that the foregoing list is not inclusive of all possible risks associated with the use of the facilities and therapies and I agree that said list no way limits the extent or reach of this release. I voluntarily accept all such risks with full knowledge and appreciation of the danger and risks involved.
  • I voluntarily agree to assume all risk of personal injury, including emotional trauma or injury, disability, paralysis, or death, and any damage to my personal property that may occur while I am at the facilities, or participating in any event or program, or while I am hiking, climbing, riding, or otherwise participating in any indoor or outdoor activity, anywhere and at any time, whether or not under the supervision of Cirque Lodge personnel. I hereby knowingly and intentionally release, and agree to indemnify, hold harmless, and defend Cirque Lodge, its owners, officers, agents, employees, staff members, contractors, and related professionals from any and all liability for such injury, disability, paralysis, death, or damage which may result from my participation in any program of Cirque Lodge or during my stay at Cirque Lodge.
  • I understand that portions of the Cirque Lodge program may be physically or emotionally demanding. I have disclosed to Cirque Lodge all of my health and physical limitations, if any, which would affect my safe use of the facilities and the therapy activities. By consenting to participation in any such activities, I acknowledge that I have sufficient good health and have no physical limitations, which would affect my safe participation in the activities. I agree that I will abide by all of the rules and regulations presented to me by representatives of Cirque Lodge, with regard to any activities. I agree to immediately comply with any specific request or instruction given to me by any representative of Cirque Lodge.
  • In the event that I suffer any injury whatsoever while participating in the activities of Cirque Lodge, or observe any other injury or dangerous condition, I agree to immediately notify an appropriate representative of Cirque Lodge.
  • I consent to have my photograph taken to be used solely for purposes of identification.
  • In the event I choose to share a ride with another resident of Cirque Lodge, or with a person unrelated to Cirque Lodge, to a Cirque Lodge meeting or activity, whether or not actually sponsored by Cirque Lodge, I understand that it is my choice to ride with such person and that Cirque Lodge assumes no liability for any injury or property damage.
  • I am eighteen (18) years of age or older and otherwise legally competent to sign this release. This release shall be binding upon me and upon my heirs, executors, administrators, assigns and members of my family.

I have carefully read this Release of Liability and fully understand and agree to its contents, and sign it of my own free will.

Signed By: on date:

Integration of all Documents

Cirque Lodge and the resident understand and agree that all of the documents and forms set forth in this admissions package constitute one entire agreement (the “Agreement”). In addition to all of the agreements, authorizations, consents, disclosures, and releases set forth in this Agreement, the parties also agree to the following provisions:

  • ASSIGNMENT: Neither party may assign any rights or delegate any duties or obligations under this Agreement without the express written consent of the other party, which consent shall not be reasonably withheld. The rights and obligations of the parties under this Agreement shall inure to the benefit of and shall be binding upon the successors and assigns of the parties.
  • GOVERNING LAW: This Agreement shall be governed by and interpreted in accordance with the laws of the State of Utah. In the event that litigation results or arises out of this Agreement or the performance thereof, the parties agree to reimburse the prevailing party’s reasonable attorney’s fees, court costs, and other expenses.
  • NOTICES: Any formal notice required by this Agreement shall be delivered in person or sent by certified mail or overnight courier to the other party at its last known address, and shall be deemed effective upon delivery or three (3) days following the mailing thereof.
  • SERVICEABILITY: If any term or condition of this Agreement is held invalid or unenforceable, the remaining terms and conditions shall remain in full force and effect and shall not be affected thereby.
  • WAIVER: The failure of either party to require performance of any terms, or the waiver by either party of any breach under this Agreement, shall not prevent a subsequent enforcement of such terms, nor be deemed a waiver of any subsequent breach.

This constitutes the entire agreement between the parties with respect to the subject matter. No modification, amendment or waiver of any of the provisions of this Agreement shall be binding upon Cirque Lodge or the resident unless made in writing and signed by both parties

Signed By: on date:

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Forms - Cirque Lodge Alcohol and Drug Rehab Center
Signature Certificate
Document name: Cirque Lodge Resident Admission Agreement
Unique Document ID: 7a6f231e2254aa14f9460699a3f9e0264bbe928b
Timestamp Audit
2016-06-20 09:38:58 MSTCirque Lodge Resident Admission Agreement Uploaded by Courtney McShay Carroll - IP