C3 Consents/Intake Packet

I, have been provided a list of service providers.  My signature below confirms that I have selected my service provider freely, without influence, pressure or coercion, direct or indirect, from any staff employed by Carolina’s Creative Counseling, PA.I have selected Carolina’s Creative Counseling, PA to be my service provider.

The following information has been provided as part of the client orientation by providing client handbook. The signatures below indicates that each area has been fully explained and is understood.

 

Rights and Grievance Procedures

Services provided, days and hours of operation, expected level of participation

Access to emergency services, after hours

Code of ethics or conduct

Confidentiality, limits of confidentiality

Methods, opportunities, and opportunity to provide input

Explanation of financial obligations, fees, and financial arrangements

Fire, safety, and emergency precautions

Policy on restraint

Policy on tobacco products

Policy on illicit or licit drugs brought into the program

Policy on weapons brought into the program

Identification of the person responsible for service coordination

Program rules, including restrictions and the loss and regaining of rights

AIDS/HIV Prevention, Hepatitis Prevention and Treatment

Client grievance procedure

Purpose and process of assessment

Individual person-centered plan

Discharge/transition criteria and procedures

I acknowledge that I received a copy of the Notice of Privacy Practices from Carolina’s Creative Counseling, PA.

 

• Confidentiality (North Carolina General Status 122-C-52):  Confidentiality applies to all facets of the individual’s life. Carolina’s Creative Counseling, PA will adhere to the client right that no confidential information acquired be disclosed by the agency. I acknowledge that Carolina’s Creative Counseling, PA has reviewed the disclosure of confidentiality with me.
• I acknowledge that I have been provided a copy of the Notice of Privacy Practices for Carolina’s Creative Counseling, PA that addresses the Health Insurance Portability and Accountability Act of 1996.
• I understand that the Notice of Privacy Practices discusses how my personal health care information may be used and/or disclosed, my rights with respect to health care information, and how and where I may file a privacy-related complaint.
• I may review a copy of the Notice of Privacy Practices in the main office of Carolina’s Creative Counseling, PA.
• I may obtain a copy of this Notice of Privacy Practices from Carolina’s Creative Counseling, PA.
• I understand that the terms of this Notice of Privacy Practices may be changed in the future, and these changes will be posted in the main office of Carolina’s Creative Counseling, PA I may also request a copy of the new Notice of Privacy Practices by contacting the Executive Director and/or designee.
• I acknowledge that I have been provided an updated copy of the Client Rights Handbook for Carolina’s Creative Counseling, PA that provides notification that information may be disclosed without consent and reasons for disclosure.
• I acknowledge that I have been provided an updated copy of the Client Rights Handbook for Carolina’s Creative Counseling, PA. I acknowledge that I have been notified and educated of individual rights.

 

I have received the policies, procedures and/or information concerning the following:

1. The rules to follow, including possible penalties;
2. My protection regarding confidential information & disclosure of such;
3. How to receive a copy of my service plan;
4. Fees charged and collection of those fees for treatment provided;
5. Grievance procedure to follow;
6. Suspension and expulsion from services;
7. Search and seizure of personal possessions; and

 

           

I understand I can contact the North Carolina Legal Assistance

 

            Their street address is:                                           Their mailing address is:

 

            2113 Cameron St., Suite 218                                   1314 Mail Service Center

            Raleigh, NC  27605-1344                                        Raleigh, NC  27699-1314

 

Phone:  (919) 733-9250 or (800) 821-6922

Website:  www.doa.state.nc.us/doa/gacpd/reach

 

I have received a copy of the client handbook and related application information.

 

I certify the above information is current and has been explained to me so that I may understand it.  I certify I had the opportunity to ask questions and had them all answered.  I further acknowledge receipt of the above information in writing, upon my admission date.

 

I give permission and consent to Carolina’s Creative Counseling, PA to transport me in any vehicles provided by or for Carolina’s Creative Counseling, PA.  I understand that it may be necessary for staff to transport in private vehicles.  The purpose for transportation is only for activities related to my treatment.

 

I release Carolina’s Creative Counseling, PA from any liability in case of accident or injury.

 

I understand that this consent may be withdrawn at any time by notifying Carolina’s Creative Counseling, PA in writing.

    I give consent to Carolina’s Creative Counseling, PA to interview, assess my situation and provide appropriate treatment to me.  I reserve the right to withdraw from this treatment at any time.  I also reserve the right to refuse any treatment offered.

I give my permission to secure emergency medical treatment if necessary.  This shall include emergency first aid by authorized personnel.  I release Carolina’s Creative Counseling, PA, its agents and employees, from all claims, demands, actions and causes of action whatsoever which I may have now or may hereafter have, as a result of any injuries which may have incurred, or of emergency medical treatment by Carolina’s Creative Counseling, PA, its agents or employees.

I understand that it is the policy of the Division of Mental Health, Developmental Disabilities and Substance Abuse Services that as a client in one of its agencies, I will receive appropriate treatment and continuity of care.  I understand that in order to accomplish this, health information may be shared between treating agencies.  (G.S. 122C-52).  I understand that this health information is contained in a computerized record system for statistical and program planning purposes.

Confidential information regarding substance abusers is released only in accordance with federal regulations (42 CFR Part 2.  “Confidentiality of Alcohol and Drug Abuse Patient Records”).  Unless such information is court ordered or by other authorized tribunal, a written authorization from the client is required to release substance abuse information.  Disclosure is also permitted in medical emergencies, to qualified personnel for research, audit purposes or program evaluation.  Federal Law does not protect any information about suspected child abuse or neglect, crimes committed by a client either at the Mental Health Facility or against any person who works for the facility or about any threats to commit such crimes.

North Carolina statues and courts prohibit certain types of health information from remaining confidential and impose a duty on the recipient of such health information to report it to the appropriate authorities, such as suspicion of child abuse and neglect of dependent children and the abuse and exploitation of disabled adults.

My rights as a client have been explained to me, and I have received a copy of the following information, which I acknowledge by initialing the pieces I have received.

 

Problem Resolution                                      

Agency rules/” Your Rights as a Client”

Notice of Privacy Practices

 

I understand that my signature gives my permission for treatment and does not waive any legal rights, including the release of the program or its agents from liability for negligence.  This consent is valid for one year from the date signed by the client.

 

 

Tele-services involves the use of electronic communications to enable health care providers at to provide services to the client for the  purpose  of  improving  client care.  The information may be used for diagnosis, therapy, follow-up and/or education. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. 

Expected Benefits: 

More efficient evaluation and management. 

Possible Risks: 

In very rare instances, security protocols could fail, causing a breach of privacy of personal  
medical information.

 

By signing this form, I understand the following: 

1. I understand that the laws that protect privacy and the confidentiality of medical information 

also apply to telemedicine, and that no information obtained in the use of telemedicine which 
identifies me will be disclosed to researchers or other entities without my consent. 

2. I understand that I have the right to withhold or withdraw my consent to the use of 
telemedicine in the course of my care at any time, without affecting my right to future care or treatment. 

3. I understand that I have the right to inspect all information obtained and recorded in the 

course of a telemedicine interaction and may receive copies of this information for a 
reasonable fee.  

Consent To The Use of Telemedicine 

I have read and understand the information provided and all of my questions have been answered to my satisfaction.  I give my informed consent for the use of tele-services in my care. 

 

Medicare and Medicaid Assignments of Benefits:  I hereby authorize Carolina’s Creative Counseling, PA to release any medical/clinical information necessary in the processing of claims and requesting payment.  I certify that the information given by me in applying for payment under Title XVIII and Title XIX of the Social Security Act is correct.  I authorize release of all records required to act on this request.  I request that payment of authorized benefits be made to Carolina’s Creative Counseling, PA on my behalf.

 

Insurance Assignment of Benefits:  I hereby appoint Carolina’s Creative Counseling, PA to file my insurance and authorize all payments to be made directly to Carolina’s Creative Counseling, PA of all benefits otherwise payable to me.  I further authorize Carolina’s Creative Counseling, PA to release diagnostic and treatment records when requested to insurance carriers in order to assist in establishing benefits.

 

Disclosure of Information:  I authorize Carolina’s Creative Counseling, PA to release medical/clinical/ information necessary in the processing of claims for payment for services.  This may include the Social Security Health Financing Administration or its intermediaries or carriers, Division of Medical Assistance and its claim processor, (Medicaid/Medicare) commercial insurance carriers and any other third party payer the client/responsible party may authorize.  If the third party coverage is through my employer, this information may be released through the employer to the third party payee. Data will include dates of service, diagnosis, name of person providing services, and any relevant charges.  Other health information may include any alcohol/drug or HIV/AIDS related treatment.  This information will be used to process payment claims only.  This consent may be revoked within (30) days of the request for revocation being completed by the client.

 

I (we) hereby discharge and release Carolina’s Creative Counseling, PA, its agents and employees, from all claims, demands, actions and causes of action whatsoever which may not have or may hereafter have, as a result of any injuries which may be incurred, or of emergency medical treatment by Carolina’s Creative Counseling, PA its agents or employees.

 

I (we) hereby give permission to secure emergency medical treatment for the above named client.  I (we) understand that the person designated below will be notified as soon as possible if an emergency requiring medical treatment, in the best judgment of the Carolina’s Creative Counseling, PA staff member, occurs.

 

I (we) understand that it is my (our) responsibility to notify Carolina’s Creative Counseling, PA of any changes to the information below.

 1. Carolina's Creative Counseling, PA requires at least 48 hours notice to cancel an appointment in order to allow our staff to reschedule another person in need for that time slot.

2. Every no show event will be documented in the chart.

3. A clinician will make an attempt to contact you and assess the reason for the no show. All attempted contacts will be documented in the chart and a no show letter may be mailed.

4. At the next scheduled appointment after every no show, the clinician should discuss with you or your family member(s) the reason for the no show, the importance of keeping scheduled appointments, and review our no show policy. The treatment plan/PCP should be adjusted accordingly based on any information obtained during this discussion.

5. After 3 no shows (consecutive or nonconsecutive), you will be placed on “call in status only”. This means no additional appointments will be scheduled for you and you will need to call your assigned therapist when you want to schedule an appointment the same day at least 2 hours prior to your desired time. If you report a need that appears to be urgent or emergent, you will be transferred to a licensed or provisionally licensed clinician for a telephone screening.

6. If the result of the telephone screening indicates an urgent or emergent need, then the clinician will instruct you and/or your family member(s) to come to the office on  a walk in basis and be seen within 2 hours (emergent), or transfer you back to the front desk staff who may give an appointment within 48 hours (for calls deemed to be urgent).

7. Any person who is out of services for 30 days will be automatically terminated from services and the case will be closed. A letter will be sent to the last known address informing you of the pending case closure at least 7 days prior to closing of the case. The letter will notify you of the specific date that your case will be closed unless you contact Carolina's Creative Counseling, PA and request additional services. This letter will also be carbon copied to any appropriate community partners who have current releases (i.e. DSS, DJJ, Probation Officers, et.) informing them of the pending case closure.

 

Your signature below indicates that you have read this policy, understand it and agree to comply with its requirements.

 

 

 

 

 

Carolina's Creative Counseling, PA maintains a process by which client grievances may be addressed in a fair, timely and impartial matter. This policy specifies how clients, family members, significant others and staff may express concern about the provision of services and what response they may expect.

Grievance may be filed on behalf of a client by:

•         The person receiving the service;

•         The parent of a minor receiving services; or

•         The legal guardian of the recipient of service; or

•         Any other adult, including a staff member, who has been designated by the client and given written consent to bring a grievance on his/her behalf.

Procedure:

 

Grievances being made by the client should be made first to the staff person with whom the client has a disagreement.  If the client is not satisfied with the response from the staff member, the client should submit a formal grievance in writing, outlining the specific grievance, previous steps taken to resolve the grievance, the parties involved and the date and time the grievance is filed. This form should be given to the Quality Management/Training Director. Clients who need assistance with completing a formal grievance may seek assistance from any employee or staff member of Carolina’s Creative Counseling, PA without fear of disclosure or retribution by assisting staff.  The Quality Management/Training Director will contact the client within 72 hours of receipt and attempt to reach a resolution with the client.  If a satisfactory resolution is not achieved through the interview with the Quality Management/Training Director, the client may submit the grievance to the Clinical Director or designee, stating the nature of the grievance, and that the client has not received a satisfactory response to the grievance. The Clinical Director or designee will respond to the grievance within 72 hours of receipt.

 

Clients who are still not satisfied with the response by the Clinical Director or designee may forward their grievance directly to the Chair of the Client Rights Committee; who will be expected to act on the grievance within five working days of receiving the report. The Client Rights Committee will investigate the grievance and will deliver an opinion regarding the resolution strategy to the agency director or designee.  Persons filing a grievance against this agency should receive a written response regarding their grievance no later than 30 days from the initial grievance filing date.

YOU HAVE THE RIGHT TO CONTACT ANY OF THE FOLLOWING ORGANIZATIONS AT ANY TIME DURING THIS PROCESS:

Provider Network LME: Mecklenburg Area Mental Health        Phone Number: (704) 336-6404

429 Billingsley Road                                                                                     Business Office: (704) 336-2023

Charlotte, NC 28211      

 

I understand that I can contact advocacy organizations; such as the Protection and Advocacy System, for more specific information on the problems I am having with my provider and for help (formal and informal) with my appeal.

2626 Glenwood Avenue, Suite 550                                                         Phone Number:          (919) 856-2195

Raleigh, NC 27608                                                                                         Toll Free Number:     (877) 235-4210 

Website: www.cladisabilitylaw.org                                                        TTY Phone Number: (888) 268-5535

Email: info@disabilityrightsnc.org                                                        Fax Number:              (919) 856-2244