Adult Intake Application

INTAKE APPLICATION
Who is completing the assessment?*

Client (Must be 18 years of age or older )Parent/Guardian for the client
Are you new to HCO Behavioral Health Services or are you an already established client?*

New ClientEstablished Client

If you are thinking about executing an advance directive for mental health treatment, read this first:

This document allows you to make decisions in advance about mental health treatment, which includes but is not limited to psychoactive medication, short-term (not to exceed 15 days) admission to a treatment facility, electroshock therapy and outpatient services. The instructions that you include in this
directive will be followed only if two physicians believe that you are “incapable”, which means that, due to any infirmity, you are currently unable to make or to communicate reasoned decisions regarding your mental health treatment.

Your instructions cannot limit the state’s authority to take you into protective custody, or to involuntarily admit or commit you to a treatment facility. Your instructions can be disregarded in an emergency if your instructions have not reduced the behavior that has caused the emergency. In a nonemergency,
you may be medicated contrary to your wishes only after an administrative review in which you are provided legal counsel.

You may also appoint a person as your representative to make treatment decisions for you if you become incapable. The person you appoint must act consistently with your wishes as expressed in this document or, if not stated, as otherwise known by your representative. If your representative does not
know your wishes, he or she must make decisions in your best interest. For the appointment to be effective, the person you appoint must accept the appointment in writing. The person has the right to withdraw from acting as your representative at any time.

This document will continue in effect for a period of five years unless you become incapable. If this occurs, the directive will continue in effect until you are no longer incapable. You have the right to revoke this document in whole or in part at any time you have not been determined to be incapable. You
may not revoke this advance directive when you are determined incapable by two physicians. A revocation is effective when it is communicated to your treating physician or other provider.

This advance directive will not be valid unless it is signed by two qualified witnesses who are personally known to you and who are present when you sign or acknowledge your signature. Also, it must be accompanied by a written mental status examination performed by a physician or psychologist attesting
to your ability to make reasoned decisions about your mental health treatment.

If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. Attorneys are available through the Mental Health Advocacy Service, 1 (800) 428-5432.
Would you like to proeed to excute an andvance diective for mental health treatment?*

YesNo
ADVANCE DIRECTIVE FOR MENTAL HEALTH TREATMENT
I Name of Principal* field. being an adult of sound mind, willfully and voluntarily make this advance directive for mental health treatment. I want this directiveto be followed if I become incapable. I become “incapable” when two physiciansdetermine that, due to any infirmity, I am currently unable to make or to communicatereasoned decisions regarding my mental health treatment.
If I become incapable, I want my mental health treatment decisions to be made:
(INITIAL ONLY ONE)
If yes, initial According to the preferences or instructions specifically authorized in this advance directive. I am not appointing a representative at this time.
If yes, initial By my appointed representative according to the preferences or
instructions specifically authorized in this advance directive, or, if my desires are not set forth in an advance directive or otherwise known by my representative, in what my representative believes to be my best interest.
1. Designation of Mental Health Treatment Representative.

Each person I appoint must accept my appointment in writing in order to serve
as my representative. By law, my representative is authorized to receive information regarding mental health treatment and to receive, review, and authorize disclosure of medical records relating to that treatment, unless limited by federal law or by my advance directive.
Limits, or additional directions
I understand that I am not required to appoint a representative in order to complete this advance directive.

I hereby appoint the following person to act as my representative to make
decisions regarding my mental health treatment if I become incapable :
Name:
Address:
Phone
(Alternate Representative - - Optional)

If the person named above refuses or is unable to act on my behalf, or if I revoke that person’s authority to act as my representative, I authorize the following person to act as my representative:
Name
Adddress
Phone
2. Psychoactive Medications

If it is determined that I am incapable, my wishes regarding psychoactive
medications are as follows:
A. The administration of the following medications:
B. The administration of medications considered appropriate by my
physician, Dr. ener doctor's name ., phone number enter phone # fields and text.
C. The refusal of the administration of the following medications. Consider giving reasons. (I understand that my refusal to accept certain medication(s) may be overruled if the medication is medically essential and the most medically appropriate. This determination is made in an administrative review in which I am provided legal counsel, and is morefully spelled out in R.S. 28:230):
3. Admission to and Retention in Treatment Facility

In the event I become incapable:
A. Initial if yes fI hereby authorize my voluntary admission to a mental health treatment facility for a period ofblank days (cannot exceed 15 days).
B. Preferences for Treatment (I understand my preferences may not be
available):

i. In the event treatment at a treatment facility is necessary, I would
prefer to be treated at the following treatment facilities (in order of
my preference)
a.
b.
c.
ii. I would prefer not to be treated at the following treatment facilities
(consider giving reasons)
a.
b.
c.
iii. My preference for a treating physician is
C. I desire that the following individual(s) be notified immediately when I have
been admitted to a mental health treatment facility:
Name
Relationship
Phone
2. Name
Relationship
Phone
4. Electroshock Therapy

A. If it is determined that I am incapable, my wishes regarding electroshock
therapy are as follows (consider giving reasons for your decision):
I. Initial if yes I consent to the administration of electroshock therapy.
(An involuntary patient must have a hearing before the administration of electroshock therapy, even if he gives consent)
II. Initial if yes I do not consent to the administration of electroshock
therapy
(consider giving reasons, conditions, and/or limitations):
5. Additional Information
A. I authorize Name of person to apply for, and administer, governmental benefits in my name.
B.. I give permission for Name of person to receive; review, and consent to disclosure of medical records relating to the treatmetn of my mental illness.
C. Other matters (consider including mental or physical health history, dietary requirements, religious concerns, and other matters of importance):
YOU MUST SIGN HERE

FOR THIS DIRECTIVE TO BE EFFECTIVE
Signature*

Clear
Printed Name and Date*
AFFIRMATION OF WITNESSES

I affirm that the person signing this directive:

(a) Is personally known to me;

(b) Signed or acknowledged his or her signature on this directive in my
presence;

(c) Does not appear to be currently unable to make or to communicate
reasoned decisions regarding his mental health treatment and does not appear to be under duress, fraud or undue influence;

(d) Is not related to me by blood, marriage, or adoption;

(e) Is not a patient or resident in a facility that I or my relative owns or
operates;

(f) Is not my patient and does not receive mental health services from
me or my relative; and

(g) Has not appointed me as a representative in this document

Witnessed by:
Signature

Clear
Printed Name
Date

MonthDayYear
Date
Printed Name
Date

MonthDayYear
Date
Signature

Clear
Client and Family Orientation Checklist

The following information has been provided as part of the consumer orientation. Signatures below indicate that each area has been fully explained and is understood by the consumer.

Services provided, days and hours of operation, expected level of participation
Client Rights and Rights of Minor Patients
Code of Ethics/Conduct
Grievances and Appeal Procedures
Discharge Procedure
Confidentiality/HIPAA
Education about advanced directives
Use of Seclusion and Restraint
Policy on Tobacco Use
Medications
Illegal Drugs
Weapons
Religion and Spirituality
After Hours Crisis Line
Emergency Preparedness
Privacy Statement
Identification of the person responsible for service coordination
Program Rules
Treatment Plan Development/Collaboration during initial assessment and every 6 months
(or as needed)
Assessments conducted by LMHP on admit and yearly (or as needed)
Collaboration with PCP, school, and appropriate referral sources (with authorization to
release)
Client's Name*
Client's Signature*

Clear
Should be Empty: