WHAT DOES ARC MANOR DO?
1. ARC Manor helps people learn to live happily without drugs and alcohol.
2. ARC Manor helps people change.
3. ARC Manor teaches people to control their own lives.
4. ARC Manor teaches people to cope with problems in their lives.
5. ARC Manor helps families transcend the effects of substance abuse.

CLIENT RIGHTS

1. You are protected by State and Federal Confidentiality Laws. See attached.
2. A person receiving care or treatment under the provisions of, or subject to 
the provision of section 7 of the PA Drug and Alcohol Abuse Control ACT (71 
p.s. 1690.107), shall retain all civil rights and liberties except as provided by 
law. No client shall be deprived of any civil right solely by reason of treatment.
3. No one is discriminated against on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, economic condition, or religion.
4. You will be treated humanely; with dignity and respect.
5. You have the right to request information about the rules, regulations, and policies regarding your treatment.
6. You have the right to review your file. If you wish to review your file, talk with your counselor. A request is then made to the Executive Director. Prior to a review, the Executive Director may temporarily remove portions if it is 
determined that the information would be harmful if presented. Reasons for
removing sections will be documented and kept on file. You may appeal this
decision in writing to the Executive Director.
7. You have the right to request the correction of inaccurate, irrelevant, 
outdated, or incomplete information from your records. The request should be addressed to the counselor/Executive Director in writing.
8. You have the right to submit rebuttal data or memoranda to your records. The material should be written.
9. You have the right to appeal termination of services to the agency director.
10. You have a right to provide input to your treatment plan.
11. You have the right to file a complaint/grievance if you are dissatisfied with services. Issues subject to grievance include length of stay, level of care 
determination, denial or termination of services, results of financial liability 
determination, and consumer abuse/neglect.

RISKS AND BENEFITS

When receiving drug and alcohol treatment there are both risks and benefits. Risks or side effects may include experiencing discomfort from sharing personal information, or discomfort from trying/applying treatment strategies to your daily living routine. There may be times of strong unpleasant feelings. This is a normal part of the counseling process and can be discussed with your therapist at any time.

There are also clear possible benefits. Benefits may include: abstinence from substance use, increase in ability to cope with stressors, a decrease in symptoms, better relationships, increased self-understanding and acceptance, and an overall feeling of being understood.

CLIENT RESPONSIBILITIES

1. You have the responsibility to fully participate in your therapy by openly and honestly disclosing your concerns.
2. You have the responsibility to keep all scheduled appointments and to cancel only when necessary and then to do so as early as possible.
3. You have the responsibility to be on time for appointments.
4. You have the responsibility to complete your homework assignments.
5. You have the responsibility for taking care of all financial obligations promptly.
6. You have the responsibility for following all the rules and regulations applicable to you.
7. You have the responsibility to put into action the changes you will be discussing in therapy.
8. You are responsible for abstaining from drugs and alcohol.
9. You are responsible to provide urine samples for drug testing. The sample 
may be sent for confirmation and you would be responsible for any cost of 
this procedure.

WHO IS ELIGIBLE FOR SERVICES

1. Any individual with a substance use disorder.
2. Any individual impacted by a substance use disorder.
3. Any individual who is motivated to change and participate in treatment.
5. Individuals coming to residential treatment should be at least 18 years old and be able to participate and benefit from our treatment program.

COMPLETION OF TREATMENT/AFTERCARE AND FOLLOW-UP

1. Treatment is considered done when the majority of your treatment goals are completed or in process and your primary therapist recommends discharge.
2. Treatment is terminated if one month has elapsed between appointments.
3. Treatment may be terminated if you are no longer willing to invest in your 
treatment.
4. Treatment may be terminated for violation of rules.
5. Treatment is best terminated after a thorough evaluation of your progress with your counselor.
6. As part of our treatment program, some individuals are contacted for follow-up.

AVAILABILITY OF SERVICES

1. Staff are available 24 hours a day every day of the year by phone.
2. Appointments are scheduled with your counselor to fit the schedules of both. Hours are flexible.

CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal law and regulations and State law. Generally, the program may not say to a person outside the program that a petient attends the program or disclose any information identifying a patient as an alcohol or drug abuser UNLESS:
1. The patient consents in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to a medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

Pertaining to the residential program, any individual leaving against facility advice will have their emergency contact informed, as long as a valid signed release of information is on file. 

Federal law and regulations do not protect any information about a crime committed by a client either at the program or against any person who works for the program or about any threat to commit such a crime.

Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.
(See 42 U.S.C. 200dd-3 and 42 U.S.C. 200ee-3 for Federal laws and 42 CFR part 2 for Federal regulations). 
(Approved by the Office of Management and Budget under Control No. 0930-0099)

The agency is required to enter into a qualified service organization agreement with the local public health agency. This allows ARC Manor to report certain diseases and conditions to the Health Department for purposes of disease prevention and control. Disease Prevention and Control Law of 1955, 35 P.S. 521.1 et seq.

My signature below acknowledges that I do voluntarily consent to enter treatment at ARC Manor. I agree to follow the treatment program which has been designed for me. All of the above has been explained to me and I have been offered a copy of this document.

Telehealth Informed Consent

ARC Manor wants to ensure you are able to receive necessary behavioral health/substance use services. In an attempt to provide this, telehealth may be an option for certain services. Telehealth is defined as a two-way interactive audio-video transmission. Telehealth includes the “originating site” where you, as the client, would be present for the telehealth session. This would be ARC Manor’s office space. The “distant site” would be where the counselor is located during the telehealth session.

This information is provided for individuals who choose to use Telehealth Services at ARC Manor. This Consent allows your authorization, explains your rights, the risks and benefits as well as reviews the contingency plan for technological failure.

You have the right to decline or refuse telehealth services. This refusal will not impact your ability to access in-person treatment options. You also have the right to confidential services. The telehealth platform that is used will be in compliance with Federal and State regulations to ensure your confidentiality is protected.

Limitation of Telehealth Services
There are disadvantages and limitations. There may be a disruption to the service, video and audio quality may not be superb, internet difficulties beyond our control may disrupt communications. These limitations often contribute to frustration about interrupting the normal flow of our interactions. There is a risk of misunderstanding one another, various details of facial expression may not be evident, and differences in tone may not be picked up. You are responsible for finding a private location, having an adequate wi-fi/internet connection and asserting the ability to minimize interruptions.

In Case of Technology Failure
Difficulties with hardware, software, equipment and/or services provided by a third party are variables that may contribute to technological failures. A technical complication may prevent or disrupt any scheduled appointment so that online video conferencing cannot be completed. In advance of your prescheduled session, your therapist will give you a phone number to use so that session may be completed via phone call. Sessions may be rescheduled.

Structure and Cost of Sessions
We continue to offer traditional face-to-face psychotherapy when appropriate and available. We will discuss how to meet your unique needs, through face-to-face or Telehealth. The structure and cost of Telehealth sessions are exactly the same as face-to-face sessions.

If you are using private insurance, we are both responsible for understanding your behavioral health benefits. You may contact your insurance provider to verify coverage for Telehealth services. In the instance that insurance does not cover your session, you will be responsible for payment.

Confidentiality:
You have all the rights discussed in ARC Manor’s Informed Consent. ARC Manor utilizes a HIPAA compliant telehealth program to ensure your confidentiality is maintained.

Attendance Policy
The attendance policy for telehealth is the same as for traditional, face-to-face services.

Emergency Management Plan
In order to participate in Telehealth you will need to identify an emergency contact and keep ready documentation of the phone number for Mental Health Crisis Service for your county.

CRISIS NUMBERS
ARMSTRONG/INDIANA: 877-333-2470
BUTLER: 800-292-3866
CLARION: 814-226-7223
WESTMORELAND: 800-836-6010

INFORMED CONSENT FOR TELEMENTAL HEALTH TREATMENT

My signature indicates that I have read and fully understand my rights and responsibilities detailed in the Telehealth Informed Consent. My signature below indicates that I have discussed those points that I did not understand and have had my questions answered. It is my understanding that if at any time during the treatment I have questions about any part of this Telehealth Informed Consent, I can talk with my clinician about them, and questions will be answered. I acknowledge that I am signing this Informed Consent for Telehealth freely and voluntarily.  I have read and understand the Informed Consent for Telehealth.

I agree to abide by and act in accordance with the points covered in this Telehealth Informed Consent. I understand that after Telehealth or other counseling services begin, I have the right to withdraw my consent at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with my clinician or the Clinical Director before ending therapy/counseling services.

I agree to enter into Telehealth therapy, if desired, with ARC Manor and to cooperate fully and to the best of my ability as shown by my signature.

 

Reminder Calls/Texts:

By signing this form, I am agreeing to receive automated appointment confirmations via calls or text message.  You may inform the front desk or your counselor if you do not wish to recieve these reminders.