INTAKE FACE SHEET

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:

4. I understand that all services will be provided regardless of gender, color, national origin, sexual orientation, religious preference, and a level of disability.
5. If there is a medical or psychiatric emergency, I give permission for staff to seek emergency care on my behalf.
6. 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.
7. 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.
8. 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.

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. 

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 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.

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:
1. nature and purpose of any services rendered;
2. the title of personnel providing that service;
3. the risks, benefits, and side effects of all proposed treatment and medications;
4.  the probable health and mental health consequences of refusing treatment; and
5. other available treatments which may be appropriate;
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.

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.

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.

Safe Place Counseling 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.

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

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.  Quality of Care
2. Outcome Achievement
3. Client Satisfaction
   

3. 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.

4. 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).
5. Orientation with the agency facilities, including emergency exits, fire suppression equipment, and first aid kits.
6. The agency policies regarding safety and:

7. Identification of direct care worker.
8. Program rules that identify:
1. Any restrictions the program may place on clients.
2. Events, behaviors, or attitudes that may lead to the loss of rights or privileges for the client.
3. Means by which the client may regain rights or privileges that have been restricted.
9. Identification of the purpose and process of assessment.
1. Smoking and Tabaco
2. Illicit or licit drugs
3. Weapons
4. Abuse and neglect and exploitation
10. Program rules governing individual conduct, risk, and consequences of non-compliance
11. Education regarding Advanced Directives, where appropriate.
12. Authorization to provide treatment and adverse reactions to treatment.
13. A description of how the Treatment Plan will be developed, treatment methodology, duration, goals, and services
14. Information regarding transition, transfer and discharge criteria and procedures.
15. Treatment alternatives/Treatment approaches.
16. Non- payment fee, all client must maintain Medicaid eligible to avoid disruption of services.
17. 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.

The provider I choose is:

Safe Place Counseling & Consulting LLC

832-831-6178

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.

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

Thank you for sumbitting your forms! We are working on processing documents and verifuing insurance. The office will contact you in 24 business hours to schedule an appointment.