Alpha & Omega Therapist and Doula Services: Intake Mental Health Form Part 1

I certify that I have insurance coverage and assign directly to Alpha & Omega Therapist and Doula Services Inc. all insurance benefits, if any, otherwise payable to me for services rendered.  I understand that I am finanially responsible for all charges not paid by insurance.  I authorize the use of my signature on all insurance submissions.  

Participant Rights for Outpatient Services 

All participants receiving outpatient services shall have and enjoy all consititutional rights of all citizens of the State of Oklahoma and the United States, unless abridged through the process of law by a court of competent jurisdiction.  Each facility providing outpatient mental health services shall insure participants have the rights specified as follows:  

1. All participants have the right to be treated with respect and dignity.  This shall be construed to protect human dignity and respect for human dignity;
2. Each participant has the right to receive services in a safe, sanitary and humane environment; 
3. Each participant has the right to receive services in humane psychological environment protecting them from harm, abuse, or neglect; 
4. Each participant has the right to receive servies in an enviornment which provides privacy, promotes personal dignity, and provides the opportunity to improve the opportunit to improve his/her functioning; 
5. Each participant has the right to receive services without regard to race, religion, sex, degree of disability, handiapping conditions, legal status, and/or ability to pay for services; 
6. No participant shall ever be neglected or sexually, physically, verbally, or otherwise abused; 
7. Each participant has the right to prompt, competent, appropriate treatment and an individualized treatment plan:  A.  The participant shall have the opportunity to participate in his/her treatment and treatment planning, and may consent, or refuse to onsent, to the proposed planning; B.  The participant's rights to consent, or refuse to consent, may be abridged for those judgen incapaitated by a court of competent jurisdiction and in an emergency situation defined by law;  C.  When the participant permits, the family/significant others may be in involved in treatment and treatment planning. 
8. The records of each participant shall be treated in a confidential manner; 
9. Each participant has the right to refuse to participate in any reseach project or medical experiment without informed consent, as defined by law.  A refusal to participate shall not affect the services available to the client; 
10. A participant may voluntarily participate in work therapy, and shall be paid just compensation for such work; 
11. Each participant has the right to request the opinion of an outside medical or psychiatric consultant, at the expense of the participant, and the right to an internal facility consultation, at no cost; 
12. Each participant has the right to assert grievances with respect to any alleged infringement of those stated, or any other subsequently statutorily granted rights; 
13. No participant shall ever be retaliated against, or subject to, any adverse conditions or treatement solely or partially because of having asserted his/her rights as aforestated in this section; 

I, the undersigned, have read, or have had read to me, the above rights.  I acknowledge tht the staff of Alpha & Omega Therapist and Doula Services, Inc. has explained my rights to me. 

Procedures for Client Grievances or Other Issues

The agency Alpha & Omega Therapist and Doula Services, Inc. wishes to maintain an open line of communication, giving the client adequate opportunity to express opinions, recommendations, and complaints.  

Who may file a Grievance:  Any client under the care of any agency or anyone interested in the welfare of a client receiving care at any agency (e.g. relative, foster parent, DHS Caseworker) may at his/her discretion provide in writing any opinion or recommendation.  

When a Grievance may be filed:  It is important that grievances be filed as soon as possible.  Grievances should be filed within five (5) days of the action grieved.  

How to file a Grievance:  Request a Grievance Form form any staff member.  Write your complaint on the form and include your ideas on a resolution of the problem.  Sign the form and return it to the Grievance Coordinator or the Program Director.  You may request assistance from the agency employee or another person in getting the form, writing, and/or filing the grievance.  The Executive Director at his/her discretion may call a meeting of the staff to give the opinion/grievance due consideraton.  Any grievance or complaint deemed to be of a serious nature will call for action by the Executive Director with the arrangements for a meeting of a staff committee.  This will occur within ten (10) working days.  The committee may take any action deemed necesary.  The client may requeset a written report from the committee, which shall be provided within thirty (30) days from the filing of the grievance or complaint.  After your grievance/complaint is filed, an attempt will be made, with your participation, to resolve the problem.  You have the right to file grievances, to receive a written response to your complaint, and to appeal if you are not satisfied with the response.  If any person attempts to deny you these rights or penalize yuo for filing a grievance, contact the Program Director.  

To Further Pursue a Grievance you may wish to contact DHS/Client Advocacy Officer at :  Advocacy Office, 900 E. Main (P.O. Box 151) Norman, Oklahoma 73070, Phone:  405-573-6605 

For more information about Grievance Procedure, contact the Director in your area:  Office of Client Advocacy (OCA) at 918-295-3101

For concerns about the Notice of Privacy Practices of Privacy Rules: CMS - Office of Secretary, Department of Health and Human Services, Washington, D. C. 20201 Phone: 877-696-6775

Office of Civil Rights, US Department of Health and Human Services, Independence Avenue SW, Room 509 F, HHS Building, Washington, D. C. 20201   OCR Hotlines - Voice: 800-368-1019

Consent for Treatment

Application is hereby made by the undersigned for voluntary admission for services of Alpha & Omega Therapist and Doula Services, Inc., as voluntary client under the provision of OS43A, Section 9-101 of the Oklahoma State Mental Health Law (2006).  

I certify that I am eighteen (18) years of age or over.  Voluntary admission may be made for any person eighteen (18) years of age or over on his/her own signature.  Any person under the age of eighteen (18) years of age may be admitted with the consent of such person and the consent of the person's parent or guardian, OS43A, Section 5-304.  

I have read, or had read to me, the following information about my rights:  

A.  All persons receiving services from his facility shall retain the rights, benefits, and privileges, graranteed by the laws and constitutions of the State of Oklahoma and the United States of America, except those specifically lost through due process of law (OS43A, Section 1-103 (h); 

B.  All persons shall have their rights guaranteed by the Client's Bill of Rights, unless an exception is specially authorized to these standards or an order of a court competent jurisdiction; 

C.  I have been given a summary of full copy of my rights as a client and fully understand the content of this document.  

I understand thta my treatment records may be subjet to review by funding sources and accrediting bodies to verify and evaluate services delivered.  

I understand the OS43A, Section 4-201 requires that each client of the agency be charged for care and treatment provided.  I have been given a copy of the current rate schedule, and I understand that payment of the charges is adjustable according to my financial ability to pay.  An individual will not be refused needed treatment because of the inability to pay:  OS, Section 1-202.  

Concent for Follow-up

Upon termination of services for the agency, Alpha & Omega Therapist and Doula Services, we may wish to contact you regarding your status and for you to answer some questions concerning satifaction of services received.  The purpose of this information is to assure the continuity of care and to provide the agency with pertient statistical information.  You may revoke permission for follow-up at any time by giving this agency written notice of by refusing to participate in any follow-up questionaire.  

By either agreeing to a follow-up call you will be contacted by either phone, email or letter to answer questions concerning my satisfaction with services received and my current status.