CTSF intake Revised

Carolina Therapeutic Services First Inc.

8401 Medical Plaza Drive, Suite 350, Charlotte NC 28262 Phone: 980-299-6631 Fax: 980-819-5055 Crisis Phone: 704-756-7082
Consumer Name: *
DOB: *

MonthDayYear
Date
SSN:*
Medicaid/Insurance #: *
ORIENTATION CHECKLIST

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

✓ Rights and Grievance Procedures

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

✓ Access to emergency services, after hours

✓ Code of ethics/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
Consumer Signature*

Clear
Legal Guardian Signature (if applicable)

Clear
Date*

MonthDayYear
Date

Carolina Therapeutic Services First Inc.

8401 Medical Plaza Drive, Suite 350, Charlotte NC 28262 Phone: 980-299-6631 Fax: 980-819-5055 Crisis Phone: 704-756-7082
Client Rights

✓ To be treated with respect and dignity

✓To have your privacy protected

✓ To develop a plan of café with services to meet your needs

✓ To participate in decisions regarding care

✓ To request information about names, locations, phones, and language for local agencies

✓ To receive the amount and duration of services you need

✓ To be free from use of seclusion or restraints

✓ To receive age culturally appropriate services

✓ To understand available treatment options and alternatives

✓ To refuse any proposed treatment

✓ To receive care that does not discriminate against you (e.g. age, race, type of illness)

✓ To be free of any sexual exploitation or harassment

✓ To receive any explanation of all medications prescribed and possible side effects

✓ To receive treatment, including access to medical care and habilitation, regardless of age or degree of MH/DD/SA disability

✓ To file a request for an administrative (fair) hearing

✓ To request and receive a copy of your medical records and ask for changes. You will be told the cost for the copying
I understand the following:
a. How to receive a copy of my service plan
b. Fees charged and collection of those fees for treatment provided;
c. Grievance procedure to follow;
d. Suspension and expulsion from services;
e. Search and seizure of personal possessions.

I understand I can contact the Governor’s Advocacy Council for Persons with Disabilities (GACPD)
I understand the benefits, potential risks, and possible alternative methods of treatment.
I understand I have the right to refuse treatment at any time but choose to consent to treatment at this time. I further understand my refusal will not be used as sole grounds for termination of services unless only viable option available.
I have received a copy of “Your Rights as a Client” and understand I have the right to be free from harm, abuse, neglect and exploitation.

By my signature below, I acknowledge that I have read and understand my rights and responsibilities as a participant in services at Carolina Therapeutic Services First Inc.
Consumer Signature*

Clear
Legal Guardian Signature (if applicable)

Clear
Date*

MonthDayYear
Date

Carolina Therapeutic Services First Inc.

8401 Medical Plaza Drive, Suite 350, Charlotte NC 28262 Phone:980-299-6631 Fax: 980-819-5055 Crisis Phone: 704-756-7082
CONSUMER CHOICE
I Type a label* have been made aware of many choices regarding services provided by other agencies and have chosen Carolina Therapeutic Services First Inc. as the provider I would like to render these services for myself and/or family
Consumer Signature*

Clear
Legal Guardian Signature (if applicable)

Clear
Date*

MonthDayYear
Date

Carolina Therapeutic Services First Inc.

8401 Medical Plaza Drive, Suite 350, Charlotte NC 28262 Phone:980-299-6631 Fax: 980-819-5055 Crisis Phone: 704-756-7082
CONSENT FOR TREATMENT

Consumer and/or Guardian of above named consumer give consent to Carolina Therapeutic Services First, In. (CTSF) and/or its DBA to authorize any routine or emergency medical, surgical, psychiatric or psychological treatment, which in the opinion of CTSF Clinical Staff deemed to be necessary to consumer’s well-being.

CTSF will inform the Consumer, Parent, Guardian, or Legal Custodian of any pending treatment that is elected and obtain his/her consent, except in the case of a life threatening emergency, at which time CTSF will act upon the advice of the physician/licensed professional on hand.

Notification will then be made as soon as possible to the guardian of the consumer.

I have read and understand the above statements and do hereby give my consent.

Copy Clause: I agree that a copy of this form may act as an original.
Consumer Signature*

Clear
Legal Guardian Signature (if applicable)

Clear
Date*

MonthDayYear
Date
This Consent shall be valid for one year from the signature date of this form.

Carolina Therapeutic Services First Inc.

8401 Medical Plaza Drive, Suite 350, Charlotte NC 28262 Phone:980-299-6631 Fax: 980-819-5055 Crisis Phone: 704-756-7082
INFORMED CONSENT FOR TELE-SERVICES

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.
Consumer Signature*

Clear
Legal Guardian Signature (if applicable)

Clear
Date*

MonthDayYear
Date

Carolina Therapeutic Services First Inc.

8401 Medical Plaza Drive, Suite 350, Charlotte NC 28262 Phone:980-299-6631 Fax: 980-819-5055 Crisis Phone : 704-756-7082
CLIENT ACKNOWLEDGEMENT OF AFTER-HOURS EMERGENCY CONTACT
I, Type a label* have been informed that Carolina Therapeutic Services First Inc. provides a 24 hours, 7 days a week emergency telephone numbers. They are:
Outpatient Therapy    (980) 299-6631           9am – 5pm

Emergency Crisis        (704) 756-7082
Crisis Response

My signature below verifies that I have reviewed Client Acknowledgement of 24 Hour On-Call Service. I have been provided the opportunity to ask questions and have the information explained to me as it relates to my treatments. I have been provided with the names of staff that will be working with me or my child and understand the days and times that each staff will be with me working toward my treatment goals. I understand that any time here is a conflict in scheduling I should call my staff member to inform them and reschedule my appointment to another date and/or time. I have been provided with a 24/7/365 Crisis Telephone number.
Consumer Signature*

Clear
Legal Guardian Signature (if applicable)

Clear
Date*

MonthDayYear
Date

Carolina Therapeutic Services First Inc.

8401 Medical Plaza Drive, Suite 350, Charlotte NC 28262 Phone:980-299-6631 Fax: 980-819-5055 Crisis Phone: 704-756-7082
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby give my consent for Carolina Therapeutic Services First to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations. (The Notice of Privacy Practices provided by Carolina Therapeutic Services First describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent.

Carolina Therapeutic Services First reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Carolina Therapeutic Services First

With this consent, Carolina Therapeutic Services First may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Carolina Therapeutic Services First may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, Carolina Therapeutic Services First may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Carolina Therapeutic Services First restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Carolina Therapeutic Services First to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Carolina Therapeutic Services First may decline to provide treatment to me.
Consumer Signature*

Clear
Legal Guardian Signature (if applicable)

Clear
Date*

MonthDayYear
Date

Carolina Therapeutic Services First Inc.

8401 Medical Plaza Drive, Suite 350, Charlotte NC 28262 Phone:980-299-6631 Fax: 980-819-5055 Crisis Phone: 704-756-7082
CONSENT FOR TRANSPORTATION

I have read and understand the transportation rules listed below for Carolina Therapeutic Services First, Inc. and I hereby voluntarily give consent for transportation by Carolina Therapeutic Services First Inc. staff members.

Transportation Guidelines/Rules:
- Consumer or legally responsible person must read and sign Consent for
  Transportation prior to receiving services or transportation being rendered.
- No weapons, drugs, alcohol or smoking, use of profanity, inappropriately touching anyone,
  leaving trash in the vehicle or throwing objects from the windows.
- Hands and objects are to stay inside and windows and doors are to remain
  closed unless driver gives permission to open.
- Do not exit the vehicle until the driver gives permission.
- Seat belts are to be worn at all times.
- The appropriate child restraint device/procedures will be used in accordance with North Carolina State law.
**Emergency Information form must accompany staff and consumers on all trips away from the home. The documents must be secured in a locked device in a locked glove compartment or trunk of the vehicle.
My signature below indicates that I have read and understand this transportation policy and consent.
Consumer Signature*

Clear
Legal Guardian Signature (if applicable)

Clear
Date*

MonthDayYear
Date

EMERGENCY CONSUMER INFORMATION
Name of Guardian
Phone Number
Please enter a valid phone number.
In case of an emergency what hospital would you prefer to be taken to?
Name of Hospital:
Address & Phone Number

MEDICAL ALERT INFORMATION
Medical Conditions:
Any known Allergies (medication, food, seasonal or other):
Current Medication:
I Type a label give consent Medical Emergency Treatment
Legal Guardian Signature (if applicable)

Clear
Consumer/Guardian Signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

Carolina Therapeutic Services First Inc.

Carolina Therapeutic Services First Inc.

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EMERGENCY CONSUMER INFORMATION

MEDICAL ALERT INFORMATION