INTAKE APPLICATION

List legal guardian information if it not mother/father ; if different from above.

Note whether mentally handicapped, emotionally handicapped, behavior disorder, learning disability, etc. Be very specific and attach or have sent by the school system the latest evaluation and/or individualized education plan. If client is in a special placement, we must have copies of testing, school records and the educational plan.

Please put a check next to all presenting problems.

Thank you for allowing us to assist you and your family in meeting its GOALS!

Consent to the Uses of Protected Health Information (PHI) as described

The Notice of Privacy Practices tells you how HCO Behavioral Health Services uses the disclosed information about you. Not all situations will be described. HCO Behavioral Health Services is required to give you a notice of our privacy practices for the information we collect and keep about you.

have been given a copy of HCO Behavioral Health Services’ Notice of Privacy Practices, and consent to the uses of my PHI as described within.

agree to consent to participate in behavioral health care services offered and provided by HCO Behavioral Health Services, a behavioral health care provider. I understand that I am agreeing and consenting to those services, that my Mental Health Professional is qualified to perform within the scope of their education, license, certification, and training of the behavioral health care staff directly supervising the services received by the client.

HCO Behavioral Health Services offers the following services:

1. Psychiatric Evaluation

2. Medication Management

3. Home and Community based Services (Medicaid Recipients)

4. Community Psychiatric Support Treatment (CPST)

5. Psychosocial Rehabilitation (PSR)

6. Crisis Intervention

Each of the services has been explained to me at an appropriate level of understanding. The benefits and risks have also been explained at an appropriate level of understanding. I have participated in the decision to which services/programs I am interested in. I agree to play an active role in developing and updating treatment plans, as needed, throughout my course of treatment with HCO Behavioral Health Services.

If the client is under the age of eighteen or unable to consent to treatment:

I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.

11408 Lake Sherwood Ave. N. Suite A Baton Rouge, LA 70816

Office (225) 261-7143 Fax (225) 250-1026 Website: www.hcohealth.com

HCO Behavioral Health Services professionals assume responsibility for the ongoing education of their clients sand families regarding emergency preparation of a disaster of natural or man-made form. These disasters include hurricanes, tornadoes, floods, terrorism, fire, winter weather, heat, and the release of hazardous materials.

HCO professionals are responsible for providing a list of community resources to contact in case of a natural disaster to the families annually.

• HCO professionals will first ensure the safety of themselves, family and property within 24 hours of an announcement of a disaster by the Louisiana Department of Homeland Security and Emergency Preparedness.
• Within 24 hours of an announcement of a disaster by the Louisiana Department of Homeland Security and Emergency Preparedness – professionals will contact the guardian of the client.
• Parent of guardian can contact the Director at 225-261-7143 or info@hcohealth.com with their intended location and
  telephone number in case of an emergency.

* In the event of an emergency evacuation, parent/guardian must keep with them:

                   1. All medications in a waterproof container
                   2. Copy of the consumer’s birth certificate in a waterproof container
                   3. Bottled water
                   4. Identification
                   5. Telephone numbers
                   6. Flash lights
                   7. Batteries
                   8. Battery-powered radio

*  HCO professional shall provide a list of current shelters, food banks, evacuation routes, etc., that are available in the family’s community.

*  Within 24 hours of the end of the disaster (or communication) is available – contact a professional to identify your location and safety.

*  In the event you are unable to contact a HCO professional, please follow all directions from the federal, state, and local government.

understand, accept, and agree with the Client/Parent/Guardian responsibilities of myself and HCO Behavioral Health Services in the event of a disaster. I will accept all responsibility if I do not follow the above outlined disaster plan.

Contract for Safety (No Suicide, No Homicide)

hereby agree that I will not harm myself in any way, attempt suicide, or die by suicide.

Furthermore, I agree that I will take the following actions if I am ever suicidal:

1. I will remind myself that I can never, under any circumstances, harm myself in any way, attempt suicide, or die by suicide.
2. I will call 911 if I believe that I am in immediate danger of harming myself
3. I will call any or all the following numbers if I am not in immediate danger of harming myself but have suicidal thoughts (please list names, phone numbers, addresses, or any other relevant contact information on the back of this sheet).

I will also call of the Suicide Hotlines listed below:
a. Hope line 24/7 (National Crisis Hotline): 1-800-784-2433
b. Crisis Hotline: 225-368-9602

 OR

c. Go to the emergency room
d. Call 911
e. Call your insurance company for instruction
I agree that these conditions are part of my counseling contract with my Therapist and are effective immediately and indefinitely.

Phone: (225) 261-7143 Fax: (225) 250-1026

at the telephone number and address above in case of a medical or mental health emergency. I understand that personal information about my medical treatment and care may be shared with the above named emergency contact person.

The permission to contact this person may be revoked at any time and immediately upon discharge. Consent to contact the above person lasts up to one year from the date of signed released.

All HCO Behavioral Health Services’ providers are trained and certified in the first aid and cardiopulmonary resuscitation (CPR) annually.

HCO professionals shall in no instance administer medications to any client or family members. BHS professionals are not liable for any harm or injury which may occur during an attempt of first aid or cardiopulmonary resuscitation (CPR

• In the event where a HCO Behavioral Health Service professional is present – there is no medically certified professional present and a client is seriously ill or hurt – the following plan shall be implemented:
• HCO professional shall act as the first aid provider
• HCO professional shall either call 911 from his/her required work cellular phone or instruct the nearest responsible adult to contact 911 emergency personnel using the BHS professional’s required work cellular phone
• HCO professional will perform an initial and ongoing assessment of an injured or ill person
• Once medical professionals arrive, the HCO professional will contact the Director to provide an oral report of the events.
• A written report of events will be completed and filed within 24 hours of medical emergency.
• In an event where the HCO Behavioral Health Services’ professional is not present and there is no medically certified professional available – the following plan shall be implemented by the adult responsible for the care of the child.

• The caregiver shall contact emergency personal at 911 immediately.
• The caregiver shall provide an initial and ongoing assessment of the ill or injured child.
• The caregiver should only provide first aid or CPR if certified or trained within a year of the event.

* If the caregiver is the guardian, the HCO professional can be contacted at 225-261-7143 or info@hcohealth.com, once medical help has arrived..

 

* A written report shall be completed and filed the following business day.

have read and understand the health and injury plan. I accept and agree with the responsibilities and will implement the above plan when necessary. If I choose not to follow the above health and safety plan, I will hold harmless HCO Behavioral Health Services (and its employees or assigned agents) for any and all damages or liabilities which may occur as a result of voluntarily not following the said plan.

 

Check All That Apply.

Member Information: I am requesting services from a mental health rehabilitation (MHR) provider. I understand that I have the right to choose an agency to provide services to me or my child. I understand that I may only receive MHR services from one provider unless my health plan makes an exception. I may change providers if I am not satisfied with the services.

If assistance is needed with finding an MHR provider, review the list of providers located at your health plan’s website below or call your plan for assistance.

1. Aetna: https://www.aetnabetterhealth.com/louisiana/find‐provider or call 1‐855‐242‐0802 Hearing impaired

2. Amerihealth Caritas Louisiana: http://www.amerihealthcaritasla.com/member/eng/tools/find‐provider.aspx

or call 1‐888‐756‐0004; TTY 1‐866‐428‐7588

 

3. Healthy Blue: https://www.myhealthybluela.com/la/care/find‐a‐doctor.html or call 1‐844‐227‐8350 (TTY 711)

4. Louisiana Healthcare Connections: https://providersearch.louisianahealthconnect.com/ or call 1‐866‐595

5. United Healthcare Community:

http://www.uhccommunityplan.com/la/medicaid/healthy‐louisiana.html

or call 1‐866‐675‐1607 TTY: 1‐877‐4285‐4514

The provider that I have freely selected to deliver MHR services to me or my child is:

1. Risk of harm to self (check all boxes below by indicating yes or no)

2. Risk of harm to others (check all boxes below by indicating either yes or no)

3. Recipient Safety and Other Risk factors (Check all the boxes below by indicating “yes or no”)

Unable to obtain Patient/Parent/Guardian/Conservator Signature

Unable to obtain Patient/Parent/Guardian/Conservator Signature

School Permission Form

Consent for Off-Site Services

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)