Client Intake

CONSENT FOR TREATMENT
1. I consent to and authorize treatment through Safe Place Counseling
2. I authorize the collection of necessary administrative dates regarding me. I understand that such data shall be computerized for statistical, programming, and billing purposes.
3. I understand information regarding me shall be collect responsibility and maintained in a confidential clinical record. Any such records or information shall remain confidential except in the following incidences:
1. Information required by third party payers and parties giving CSC authorization to provide said services shall be forwarded to them.
2. Records shall be open to Safe Place Counseling staff as needed and to appropriate state mental health officials.
3. Information may be exchanged if I sign a written release form indicating the nature of information to be released.
4. Information, which indicates a severe threat to the life or safety or another person or to self, shall be forwarded to the threatened parties or appropriate agencies to the extent necessary to protect life and safety.
5. Information will be released if required under a court subpoena.
6. Suspected abuse or neglect shall be reported to Protective Services as mandated by the Code of Texas and Federal Law.
7. State and Federal law prohibits the disclosure of any information identifying a Recipient as receiving alcohol/drug services unless the Recipient consents in writing, the disclosure is allowed by court order, disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluations.
8. Federal Law does not protect any information about a crime committed by a Recipient either at the program or against any person who works for the program or about any threat to commit such a crime
1. I understand that all services will be provided regardless of gender, color, national origin, sexual orientation, religious preference, and a level of disability.
2. If there is a medical or psychiatric emergency, I give permission for staff to seek emergency care on my behalf.
3. Safe Place Counseling staff may share information with my consent with other associated facilities such as group homes, Dept. of Social Services, Court Services, and Area Programs if a Recipient is seen in two or more of these agencies.
4. I agree to satisfy my financial obligation with Safe Place Counseling. I understand payment is due at the time services are rendered unless payment arrangements are made.
5. You have the right to accept or refuse any medication, procedure test or treatment. Exception to this right is when there is an emergency, court order or if the recipient is under 18 years old and his/her parent or guardian has given permission.
I understand that I will be receiving the following services provided by Safe Place Counseling:

Assessment/ ReassessmentSkills Development and TrainingIndividual /Family Intervention CounselingMedication Training and SupportIntensive Case ManagementGroupOther
Recipient or Legally Responsible Person

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INFORMED CONSENT FOR TEL-SERVICES
Tele-services involve 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.
Client or Legal Guardian

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Medication Therapy Management Consent Form
I have elected to make use of the medication therapy management services providedby Safe Place Counseling. My participation is voluntary. I understand that these services are not a direct substitute for medical care provided by my physician or any other provider.
I understand that this consent is revocable upon written notice

YesNo
I authorize Safe Place Counseling to maintain a copy of my health profile and medication related recommendations for the purpose of follow-up and monitoring.

I understand that every effort will be made to maintain the confidential nature of my private health information. Information about this review will not be shared with anyone except my legal representative without my written consent.
Recipient or Legally Responsible Person

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CLIENT’S RIGHTS AND RESPONSIBILITIES
Safe Place Counseling’s policy is to protect the rights of each client. During the intake process, the client’s rights are reviewed in a manner that is understandable. The Corporate Compliance Officer responds to questions and grievances pertaining to the client’s rights and ensures compliance with Texas administrative code. Rule §404.154. The client’s rights and responsibilities are reviewed annually as listed below.

CLIENT RIGHTS:
1. to be informed of the client's rights and responsibilities at the time of admission or within 24 hours of admission;
2. to have a family member, chosen representative and/or his or her own physician notified of admission to the BHS provider at the request of the client;
3. to receive treatment and medical services without discrimination based on race, age, religion, national origin, gender, sexual orientation, or disability;
4. to maintain the personal dignity of each client;
5. to be free from abuse, neglect, exploitation and harassment;
6. to receive care in a safe setting;
7. to receive the services of a translator or interpreter, if applicable, to facilitate communication between the client and the staff
8. to be informed of the client’s own health status and to participate in the development, implementation and updating of the client’s treatment plan;
9. to make informed decisions regarding the client’s care by the client or the client’s parent or guardian, if applicable, in accordance with federal and state laws and regulations;
10. to participate or refuse to participate in experimental research when the client gives informed, written consent to such participation, or when a client’s parent or legal guardian provides such consent, when applicable, in accordance with federal and state laws and regulations;
11. to be informed, in writing, of the policies and procedures for filing a grievance and their review and resolution;
12. to submit complaints or grievances without fear of reprisal;
13. to have the client’s information and medical records, including all computerized medical information, kept confidential in accordance with federal and state statutes and rules/regulations;
14. to be given a copy of the program's rules and regulations upon admission;
15. to receive treatment in the least restrictive environment that meets the client’s needs;
16. to not be restrained or secluded in violation of federal and state laws, rules and regulations;
17. to be informed in advance of all estimated charges and any limitations on the length of services at the time of admission or within 72 hours (There are no out of pocket fees associated with services provided to Medicaid recipient’s)
18. to receive an explanation of treatment or rights while in treatment;
19. to be informed of the:
20. to accept or refuse all or part of treatment, unless prohibited by court order or a physician deems the client to be a danger to self or others or gravely disabled;
21. to have a copy of these rights, which includes the information to contact Safe Place Counseling
CLIENT RESPONSIBILITIES:

To make your mental health treatment successful, we need to work together. The agency asks that all clients provide clear, complete, and truthful information always. We do our part by providing you with information concerning your rights and the services we offer. Your part is to take responsibility for the following:
1. Follow agency rules, policies, and procedures.
2. Follow the steps described in this handbook if you wish to file a grievance or appeal with our agency.
3. Keep scheduled appointments and call to cancel or reschedule if you cannot make your scheduled appointment.
4. Ask questions when you do not understand or when you want more information.
5. Provide any information to your worker that is necessary for your treatment.
6. Participate actively to create goals that will help you in your recovery.
7. Follow the treatment plans that you and your providers have agreed upon.
8. Take medications as they are prescribed for you.
9. Tell your doctor if you are having unpleasant side effects from your medications, or if your medications do not seem to be working to help you feel better.
10. Seek out additional support services in the community.
11. Invite the people (family, friends, etc.) who will be helpful and supportive to you to be included in your treatment.
12. Understand your rights and the grievance process.
13. Treat staff, as you would expect to be treated.
Recipient or Legally Responsible Person

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PRIVACY NOTICE ACKNOWLEDGMENT FORM (HIPPA)
I acknowledge that I have been provided a copy of the Notice of Privacy Practices for Safe Place Counseling. 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 from Safe Place Counseling office.

I may obtain a copy of this from Safe Place Counseling

I understand that the terms of this Notice may be changed in the future, and these changes will be posted in Safe Place Counseling office. I may also request a copy of the new Notice by contacting the Privacy Officer.
Recipient or Legally Responsible Person

Clear
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CRISIS RESPONSE SERVICE
I have been informed that Safe Place Counseling has a crisis response line (713-429-5114) available 24hrs /7 days a week, 365 days a year for Recipient to use in crisis situations. A designated on-call qualified professional will be responsible for responding to all crisis calls during and after regular business hours. The on call qualified professional will be responsible for the implementation of Crisis Plan via phone and face to face within two hours. The on call qualified professional will have access to the crisis plan for everyone.
Recipient or Legally Responsible Person

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RIGHT OF DETERMINATION APPEAL PROCESS
CSC will not deny, interrupt, suspend, reduce, or terminate your services without a good cause. If you are a Medicaid recipient (or eligible to be one) and a decision has been made to deny, reduce, suspend, or terminate services being received, then you have the right to appeal the decision.

A notification of the decision will be sent by your MCO. If you need clarifications on any issues, please contact Safe Place Counseling immediately. We will assist you with the appeal process follow up.

Recipients maybe expelled or suspended from services when the agency can no longer meet the recipient’s needs or guarantee their safety. Safe Place Counseling shall notify recipients once a specific time is determined to restore services. Safe Place Counseling shall make efforts to recommend appropriate services that will meet recipient’s needs and discharge plan if any.
Recipient or Legally Responsible Person

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ABUSE / NEGLECT PROTOCOL / PROCEDURE
It is your right to be free of harm, abuse, neglect, and exploitation. Safe Place Counseling prohibits any abuse or neglectful conduct on the part of any individual employed or contracted by the agency or serving in a consultative capacity.
If for any reason, you have questions, concerns or complaints that involve any kind of abuse, sexual, physical etc. you should call the Texas Department of Family and Protective Service at 1-800-252-5400
Recipient or Legally Responsible Person

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AUTHORIZATION FOR SCHOOL VISITS
I Parent/Legally responsible person do give Safe Place
Counseling staff the permission to visit my child at school to provide mental health rehabilitation services to my child.
Child Name
School Name
School Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
School Phone Number
Please enter a valid phone number.
School Counselor Name
Grade:
Teacher’s’ Name
Recipient or Legally Responsible Person

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Client Orientation Checklist
Each client, parent, or legal guardian of a client will be instructed and given written information regarding the following, upon admission to Safe Place Counseling’s program:
- Informed Consent/Freedom of Choice
- Non-discrimination provisions
- family involvement.
- safety.
- the rules governing individual conduct.
- authorization to provide treatment.
- adverse reactions to treatment.
- the general nature and goals of the program.
- proposed treatment to include treatment methodology, duration, goals, and services.
- risks and consequences of non-compliance.
- treatment alternatives.
- client’s rights and responsibilities.
- all other pertinent information, including fees and consequences of non-payment of fees.
· Additional information will be provided throughout the intake process, including but not limited to:
1. Grievance and Appeal Procedures
2. Communication/input policies regarding
1. Explanation of the agency’s
- Mission/Philosophy/General nature and goals of the program
- Services, activities, and therapeutic interventions
- Family Participation/Involvement
- Hours of Operation
- 24-Hour on Call Policy
- Code of Ethics
- Confidentiality Policy and HIPPA Privacy Rights
- Requirements for follow-up for mandated clients, regardless of his/her discharge outcome.
1. Explanation of all financial obligations, fees, and arrangements for services provided by the organization (There are no out of pocket fees associated with services provided to Medicaid recipient’s).
2. Orientation with the agency facilities, including emergency exits, fire suppression equipment, and first aid kits.
3. The agency policies regarding safety and:
1. Seclusion, restraints, or physical holds
2. Smoking and Tabaco
3. Illicit or licit drugs
4. Weapons
5. Abuse and neglect
1. Identification of direct care worker.
2. Program rules that identify:
3. Identification of the purpose and process of assessment.
4. Program rules governing individual conduct, risk, and consequences of non-compliance
5. Education regarding Advanced Directives, where appropriate.
6. Authorization to provide treatment and adverse reactions to treatment.
7. A description of how the Treatment Plan will be developed, treatment methodology, duration, goals, and services
8. Information regarding transition, transfer and discharge criteria and procedures.
9. Treatment alternatives/Treatment approaches.
10. Non- payment fee, all client must maintain Medicaid eligible to avoid disruption of services.
11. Health and Safety concerns inclusive of physical and Environmental safety, Waste Management, and Infection Control Factors.
By signing this acknowledgement, I agree to the terms of all contents of the Client Orientation/Intake Process and have received a copy of the Client Handbook.
Recipient or Legally Responsible Person

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Member’s Freedom of Choice Form
The provider I choose is:

Safe Place Counseling & Consulting PLLC

832-271-3344

By Signing below, I acknowledge that I freely choose to receive services from the above provider, and I acknowledge my responsibility to notify my previous provider to coordinate care.
Member Name:
Member Date of Birth:

MonthDay Year
Date
Member Legal Guardian Signature:

Clear
Legal Guardian Name:
Member’s Insurance Provider:
Date

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Recipient or Legally Responsible Person

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SAFE PLACE COUNSELING LLC

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice, please contact: Privacy Officer

Safe Place Counseling & Consulting
Location
Phone: 832-271-3344

This notice describes how medical information about a recipient may be used and disclosed and how to gain access to the above information. Please review it carefully.

All information that is provided during the screening, admission, and treatment/rehabilitation process is considered confidential by the employees, interns, and volunteers of Comcare. We are required to protect the privacy of health information of a recipient, and the disclosure of protected health information will be governed by the Health Insurance Portability and Accountability Act of 1996, as well as any other applicable federal or state laws.

Exchange and use of protected health information between Safe Place Counseling staff and/or Safe Place Counseling programs for the purpose of treatment, payment, or healthcare operations will be permitted and based on “need to know” guidelines, and positional authority. For example:

Information obtained about a recipient by a psychiatrist, therapist, case manager, nurse or other member of the treatment team will be recorded in recipient’s record and used to determine the course of treatment that should work best for the recipient.

Treatment team members will also be expected to discuss recipient progress with treatment on a routine basis.

Information about the services received will be submitted and processed by the billing department so that the Agency can be paid, or the recipient can be reimbursed.

Recipient medical record may also be pulled for review by the Quality Improvement department in preparation for an audit or for other internal reviews to improve the quality and effectiveness of the services being provided.

Disclosure of protected health information outside of Safe Place Counseling is permitted when recipient or their legal representative signs a written authorization or gives verbal authorization in an emergency. Any authorization for disclosure may be revoked at any time, except to the extent that action has been taken in reliance on it.

Recipients have the right to request restriction of the disclosure of their health information, except

when Safe Place Counseling is required to do so. Even without recipient specific consent, Safe Place Counseling may disclose information to someone outside of Safe Place Counseling(and in some cases Safe Place Counseling may even be required by law or professional ethics to disclose recipient information), in the following situations:

When there is a medical or psychiatric emergency involving recipient health or safety or safety of others.

When Safe Place Counseling is required by law to report instances of neglect or abuse of a child or disabled adult.

Disclosure in a legal proceeding, where Safe Place Counseling is responding to an order of a court or administrative tribunal.

When Safe Place Counseling is required by Texas Administrative Code to disclose to the physician, information due to an incident which would cause health risk to other persons.

When Safe Place Counseling authorizes research for the purpose of program planning and evaluation of services using statistical information that cannot be linked to the recipient as an individual.

Recipients also have other rights related to the use and disclosure of health information in their medical record.

These rights include:

Right to request recipient medical record be designated as secured

All medical records are secure and confidential. Recipient may restrict the disclosure of their medical records only for the purpose of treatment, payment, or healthcare operations. Safe Place Counseling will make every effort to accommodate recipient request, but we are not required to do so. For example, if the information is the subject of a lawsuit or legal claim or if release of the information may present a danger to you or someone else.

Right to inspect and request a copy of recipient medical record.

If recipients would like to inspect or receive a copy of their health information, please contact Safe Place Counseling for instructions on how to submit a written request. The agency may deny recipient request in limited circumstances. If request is denied, Safe Place Counseling will respond to the recipient in writing, stating why the request was not granted and describing any rights to request a review for denial. If recipient request is approved, the agency may charge a reasonable fee for the costs of copying, mailing or other supplies associated with any request for copies.

Right to request amendment of any section of recipient medical record.

If recipients feel that the agency has information that is inaccurate or incomplete, recipients have the right to request amendments of record. If request is denied, the agency will notify recipient in writing of the reason and will describe recipient rights to provide a written statement disagreeing with the denial.

Right to receive an accounting of disclosures that have occurred.

Each disclosure of protected health information will be documented in the medical record. Recipients have the right to request an accounting of the disclosures of previous years, if any.

Right to request an alternative method of contact.

Safe Place Counseling may call recipients or mail information regarding appointment reminders, billing information, or other information about treatment alternatives or services that might be of interest. If

recipients would like to request an alternative method of contact, please notify the agency. Safe Place Counseling will accommodate reasonable requests, but may condition our accommodation on recipients providing, information regarding how payment, if any, will be handled.

Right to a copy of this Notice.

Recipients have the right to receive a paper copy of this Notice. Safe Place Counseling reserves the right to change this notice and to make the new notice effective for all protected health information that is maintained in hard copy or electronic format. Revisions to the

NOTICE OF PRIVACY PRACTICES will be made available at each facility for distribution to all recipients.

Safe Place Counseling recognizes the importance of confidentiality, and recipient’s right to be fully informed of all regulations regarding protected health information.

If recipients feel that their privacy rights have been violated, they may contact:

Safe Place Counseling

713-429-5114

OR

Office of Consumer Services and Rights Protection

Phone: (800) 252.8154

Fax:(512) 706-7353

1106 Clayton Lane

Austin, Texas 78723 Mail Code: H700

OR

Texas Department of Family and Protective Service

Call: 1-800-252-5400

If you cannot use the Texas Abuse Hotline you can. Report online a
www.TxAbuseHotline.orgExternal Link

Provision of services will not be affected by the filing of any complaint
Recipient or Legally Responsible Person*

Clear
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Should be Empty:

	Name of Medication	Dosage	Frequency	Duration	Prescriber

INTAKE FACE SHEET

Emergency Contact Information

Client Data Form

MEDICAL HISTORY Questionnaire

CONSENT FOR TREATMENT

INFORMED CONSENT FOR TEL-SERVICES

Medication Therapy Management Consent Form

CLIENT’S RIGHTS AND RESPONSIBILITIES

CLIENT RIGHTS:

PRIVACY NOTICE ACKNOWLEDGMENT FORM (HIPPA)

CRISIS RESPONSE SERVICE

RIGHT OF DETERMINATION APPEAL PROCESS

ABUSE / NEGLECT PROTOCOL / PROCEDURE

EMERGENCY PREPARDNES QUESTIONNAIRE

AUTHORIZATION FOR SCHOOL VISITS

Client Orientation Checklist

Member’s Freedom of Choice Form

CONSENT TO RELEASE OR OBTAIN INFORMATION

SAFE PLACE COUNSELING LLC

Safe Place Counseling & Consulting

Phone: 832-271-3344

Texas Department of Family and Protective Service