Pathways Intake Package

Pathways Intake Package

Please complete all the forms and then hit "Submit" on the Signature Page.
I am a (choose one):

New Consumer (I have never received services from Pathways.) Returning Consumer (I have received services from Pathways in the past.)
Name *

First Name Last Name
Gender

Female Male
IF APPLICABLE, Parent/Guardian/Legal Representative

First Name Last Name
Consumer Date of Birth *

Month Day Year
Date
Consumer Social Security Number *
000-00-0000
Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

CONSUMER ORIENTATION ACKNOWLEDGEMENT

Please review the Consumer Orientation Manual found on the Pathways website: www.Pathways-ky.org / Telehealth / Consumer Resources
As a consumer of Pathways, Inc., upon admission I have been instructed in or given written materials regarding the following. I understand my therapist will be reviewing this information with me at my first appointment.

● Rights and responsibilities of the person served.

● Notice of Privacy Practices

● Grievance and appeal procedures.

● Ways in which input is given.

● The organization’s:

1.   Confidentiality policies.

2.   Intent/consent to treat.

3.   Behavioral expectations of the person served.

4.   Transition criteria and procedures.

5.   Discharge criteria.

6.   Response to identification of potential risk to the person served.

7.   Access to after-hour services.

8.   Standards of professional conduct related to services.

9.   Requirements for reporting and/or follow-up for the mandated person served, regardless of his or her discharge outcome.

● An explanation of any and all financial obligations, fees, and financial arrangements for services provided by the organization.

● Any and all financial obligations, fees, and financial arrangements for services provided by the organization.

● The program’s health and safety policies regarding:

1.   The use of seclusion or restraint.

2.   Use of tobacco products.

3.   Illegal or legal drugs brought into the program.

4.   Prescription medication brought into the program.

5.   Weapons brought into the program.

● Missed Appointment Policy

● The program rules and expectations of the person served which identifies the following:

1.   Any restrictions the program may place on the person served.

2.   Events, behaviors, or attitudes and their likely consequences.

3.   Means by which the person served may regain rights or privileges that have been restricted.

● Familiarization with the premises, including emergency exits and/or shelters, fire suppression equipment, and first aid kits.

● Education regarding advance directives, if appropriate.

● Identification of the purpose and process of the assessment.

● A description of:

1.   How the person-centered plan will be developed.

2.   The person’s participation in goal development and achievement.

3.   The potential course of treatment/services.

4.   How motivational incentives may be used.

5.   Expectations for legally required appointments, sanctions, or court notifications.

● Identification of the person(s) responsible for service coordination

GENERAL CONSENT TO CARE AND TREATMENT AND ACKNOWLEDGEMENT FORM
PERMISSION FOR TREATMENT
I hereby authorize staff of Pathways to render any examination, prescription of medication, treatment procedures, or therapy rendered to the individual listed below whether it be a face-to-face service or telehealth. *
Name
who is
APPOINTMENT REMINDER CALLS: As a courtesy, Pathways places appointment reminder calls to its consumers which includes leaving a message if the consumer is unable to answer the call. If you don’t want to receive appointment reminder calls, please advise the Customer Service Representative prior to signing this Acknowledgement Form.
EMERGENCY MEDICAL AUTHORIZATION: I, the undersigned, do hereby authorize Pathways, Inc. and its agents or representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
CONSUMER CONFIDENTIALITY STATEMENT: As a consumer of services provided by Pathways, Inc., I understand that the identity of other consumers is confidential. I understand that Federal Law and regulations protect the confidentiality of each individual who receives services from Pathways, Inc.

I will respect other consumers’ confidentiality. I understand that if I obtain information regarding another consumer, including but not limited to, the fact that an individual is being treated at Pathways; and/or, if while attending a group service, should I learn any additional information regarding an individual, I cannot discuss this outside of the program.

I understand that there could be penalties for failure to comply with the above statements, including possible civil penalties.
PATHWAYS CONFIDENTIALITY STATEMENT: In general, the privacy of all communications between a consumer and Pathways is protected by law, and Pathways can only release information about our work to others with written permission; however, there are a few exceptions.
- In most legal proceedings, you have the right to refuse permission for Pathways to provide any information about your treatment. However, in some proceedings, such as child custody and others in which your emotional condition is an important issue, a judge may order testimony from a Pathways employee, in which case we will comply with the order.
- There are some situations in which Pathways is legally obligated to take action to protect others from harm, even if we have to reveal some information about your treatment. For example, if we believe that a child, elderly person, or disabled person is being abused, we must file a report with the appropriate state agency.
- If Pathways believes that you are threatening serious bodily harm to another, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for you. If you threaten to harm yourself, we may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection. If a situation like this occurs, we will make every effort to fully discuss it with you before taking any action.
- Pathways professionals function from an Interdisciplinary team approach and consult with each other regarding the treatment of consumers. All employees of Pathways are legally bound to keep the information confidential.

FEE AGREEMENT

My signature on the signature page indicates I agree to the conditions described in the sections below.
I am a resident of Pathways' catchment area (Bath, Boyd, Carter, Elliott, Greenup, Lawrence, Menifee, Montgomery, Morgan, and Rowan County).

Yes No
Total Family Annual Income:
Number of family members in the household:
FEE ASSESSMENT: I agree to pay Pathways the amount of fees that my third party guarantor reports I am responsible for paying. In the event I do not have a third party guarantor, or my third party guarantor does not cover the particular service I may receive, I agree to pay the fees listed in Pathways' Sliding Fee Scale. These fees are subject to change when either: (1) there is a change in my ability to pay such as employment status or third party coverage or, (2) on the annual anniversary date of my current Fee Agreement or, (3) when Pathways determines that current Fee Agreement conflicts with the agency's fee policy and/or fee scale. I also understand that payment is due at the time of service unless I have made arrangements with the office staff. Furthermore, I certify that all financial information provided is true, complete, and accurate, to the best of my knowledge. I understand that should it be determined that such information is not true; I will be responsible for paying Pathways' full fee for all services rendered from the date of this agreement. I understand that this agreement replaces any previous fee agreements. I have received a copy of the Fee Scale.
SUBSCRIBER'S ASSIGNMENT OF BENEFITS: I hereby authorize my insurance company to pay directly to Pathways, Inc. for services rendered any and all sums of money otherwise payable to me under the terms and conditions of said insurance contracts. In the event that such payment is insufficient to meet the total charges for my account, I understand I am financially responsible and obligated to pay all charges not covered by this assignment.
CONSUMER'S RELEASE OF INFORMATION FOR INSURANCE BILLING PURPOSES: I authorize Pathways, Inc. to release my medical records, including any alcohol or drug abuse data protected by Federal Regulation (42 CFR Part 2) or otherwise, together with any information relating to mental or emotional conditions, to any agency, insurance company, or other entity which might require them to process any claim on my behalf. I understand such information will NOT be released for any other purpose without my written consent. I understand I may revoke this authorization at any time in writing. If I do not, it will remain in effect for 24 months from the date I sign it.
AUTHORIZATION FOR PATHWAYS TO ASSIST IN APPEALS OR REQUESTS WITH MANAGED CARE ORGANIZATION: In the event that I have Medicaid coverage through a Medicaid Managed Care Organization (MCO) and that MCO denies a service authorization or approves less than what has been requested, I authorize Pathways to file an appeal.

E-MAIL AUTHORIZATION FORM
I request Pathways, Inc. to use electronic mail (e-mail) to communicate clinical information to me pertaining to health care services that I have received. I acknowledge and understand that e-mail communication may contain my personal and private medical information including, but not limited to, my name, address, date of birth, types and dates of health care services received, medication, insurance coverage information, and/or test results.

I understand that, although Pathways, Inc. may attempt to protect the privacy of the contents of email sent to me and will take reasonable measures to protect my privacy, the e-mail messages sent to me are not encrypted and travel over the Internet. As a result, there is a risk that the e-mail will be intercepted and read by unauthorized third parties. In allowing Pathways to send me e-mail, I assume this risk.

I also acknowledge and understand the following as it relates to this e-mail communication
- I understand the psychotherapy will not be conducted via e-mail.
- If an e-mail has not been answered, I may make an appointment to see/speak with the therapist to discuss my concerns.
- I will not use e-mail for discussion of sensitive or highly confidential issues.
- I understand that all e-mail correspondence will be included in my electronic health record.
- I, and not Pathways, Inc., am responsible for the security of e-mail communications sent to, from, or stored on my computer.
- My decision to allow Pathways, Inc. to communicate with me by e-mail is voluntary, and that treatment is not conditioned upon my election to do so.
- I may stop e-mail communication at any time for any reason. If I choose to stop this form of communication, I will inform my therapist at Pathways of that decision.
- I agree to notify my therapist at Pathways, Inc. when my e-mail address changes, and I will complete a new E-mail authorization Form.
- I will not hold Pathways, Inc. responsible for damages resulting from their use of e-mail or the failure of any Pathways, Inc. information systems used to facilitate the e-mail communication.
- E-mail is not appropriate for conveying information relating to emergency medical matters.
Pathways, Inc. is authorized to respond to and/or send medical information to my e-mail address listed above.

IF YOU ARE EXPERIENCING A MENTAL HEALTH CRISIS OR FEELING SUICIDAL, DO NOT USE EMAIL TO COMMUNICATE.

CALL OUR 24/7 HELP LINE AT 1-800-562-8909

PRESCRIBER SERVICES AGREEMENT
Pathways provides a multitude of behavioral health services, one of which is an evaluation for medication by a prescriber. Medication is often helpful in the treatment of behavioral health problems. It is important to note Pathways is not a medication-only clinic.
- Medication is only prescribed if a consumer is involved in other Pathways outpatient therapy services. If a Pathways prescriber makes the recommendation of medication, Pathways requires consumers to also be involved in Pathways therapy services as recommended.
- Every consumer who receives medication is required to see a Pathways therapist at least every three months to update his/her treatment plan. If the consumer does not keep his/her appointment with the Pathways therapist, he/she will not be scheduled to see the prescriber.
- Pathways requires consumers to be seen as recommended by the Prescriber to receive a prescription, so consumers should keep appointments. Refills will not be called in for consumers who do not keep appointments.
- Consumers need to bring a complete list of all medications he/she is currently prescribed by any other doctor or nurse practitioner.
I recognize and agree to receive prescriber services from Pathways under the terms outlined herein and hereby agree to follow these terms in order to receive prescriber services from Pathways. I further recognize that prescriber services will not be provided and/or cancelled in the event that I do not follow the terms of service.

SIGNATURE PAGE
Date

Month Day Year
Date
Typing my name below indicates I have read and agree to the terms of the forms listed:
- General Consent to Care and Treatment and Acknowledgement Form
- Authorization for Release and Exchange of Confidential Information with Primary Care Provider
- E-mail Authorization Form
- Consumer Orientation Acknowledgement
- Prescriber Services Agreement
- Fee Agreemen t
TYPING MY NAME BELOW REPRESENTS MY SIGNATURE: *

First Name Last Name
If applicable, Parent/Guardian or Legal Representative Name:

First Name Last Name
Signature (Optional)
Should be Empty:

Pathways Intake Package

AUTHORIZATION FOR RELEASE AND EXCHANGE OF CONFIDENTIAL INFORMATION WITH PRIMARY CARE PROVIDER

CONSUMER ORIENTATION ACKNOWLEDGEMENT

GENERAL CONSENT TO CARE AND TREATMENT AND ACKNOWLEDGEMENT FORM

FEE AGREEMENT

E-MAIL AUTHORIZATION FORM

PRESCRIBER SERVICES AGREEMENT

SIGNATURE PAGE