Enrollment Package with Virtual Services Form

Enrollment Full Package with Virtual Services Form
PERSONAL DATA INTAKE INFORMATION FORM
Please provide all the required documentation. Please do not leave any blank spaces. All the information is kept in strict confidence and may not be disclosed without your permission.
Name*

First NameLast Name
Middle Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:*
Work Phone:*
Ext
Mobile Phone:*
Email Address:*
example@example.com
Best Way to Contact You:*
How did you hear about our Program?*

INTAKE: Self Alcohol/Drug Assessment
Name:*
Date:*

MonthDayYear
Date
Please answer all the following questions. All the information is kept in strict confidence and may not be disclosed without your permission.
1. At what age were you when you first took one or more drinks or used drugs?*
2. How old were you when you first became intoxicated or high?*
3. How many years have you been drinking or using?*
4. How often do you drink or use?*

DailyWeeklyMonthlyOther
5. What is the most positive or desirable effect of alcohol or drugs for you?*
6. When was your last drink, or use?*
How much?*
7. What particular situations or feelings would likely make you drink or use?*
8. Have you had periods of not remembering events, during, or after the time you were drinking?*
9. Have you had any medical problems directly related to drinking or using?*
10. How is your general health?*
11. Do you feel that you have a drinking or drug problem impacting your life now?*
12. In what ways has your drinking or using caused you problems?*
13. Do you consider your drinking or using to be alcoholic/addictive?*
14. What was your Blood Alcohol Content at the time of your arrest?*
Do you feel you were in control?*
15. Are you currently taking prescription medication?*
lf so, what?
16. Have you used street drugs in the past? (cocaine, methamphetamine, pot, etc.)*
_ lf so, what?
17. Are you currently using drugs?*
lf so, what?
18. Have you attended counseling (marriage, family, Individual, alcohol/drug treatment)?*
If so, when?
19. Have you considered or been suggested to attend AA/NA?*
If so, are you attending?
20. Is anyone in your family alcoholic or drug dependent?*
lf so, who?
21. Legal History? (Current)*
(Past)*
22. Current Age?*
23. Are you employed?*
Signature:*

Clear
Client's Name:*

Driving Under the Influence (DUI) Program Enrollment Participant Information/Informed Consent and Agreement
DUI program services in California must be completed through the Department of Health Care Services (DHCS) licensed DUI program. California’s Health and Safety Code (HSC), Division 10.5, Part 2, Chapter 9, Section 11836 establishes the DHCS as having the sole authority to license DUI Programs to provide alcohol or drug recovery services to a person whose license to drive has been administratively suspended or revoked for, or who is convicted of, a violation of Section 23152 or 23153 of the Vehicle Code (VC), and admitted to a program pursuant to Section 13352, 23538, 23542, 23548, 23552, 23556, 23562, or 23568 of the Vehicle Code.

Pursuant to Title 9, California Code of Regulations (CCR), Chapter 3, Section 9848, a DUI program may enroll any person who presents documentation from the court or the DMV verifying his/her arrest or conviction for a DUI violation specified in HSC Section 11836 as referenced above. To ensure timely program enrollment, DHCS will allow several types of documents generated by the DMV or court. (See DHCS acceptable Enrollment Document Matrix)

Although DHCS licenses DUI program services, program requirements are ultimately dependent on offenses specified in California Vehicle Code, and interpreted by the California Department of Motor Vehicles (DMV)-Mandatory Action Unit (MAU), in conjunction with the court of conviction.

When enrolling in a DUI program following arrest for a DUI offense prior to a conviction, the DUI program will enroll you in the most appropriate program type based on the information contained in the enrollment documents you present along with any additional information you are able to provide at that time. DHCS encourages you to contact the DMV-MAU at (916) 657-6525 if you have questions/concerns specific to the type of DUI program you will ultimately be required to complete.

Please note, following your initial DUI program enrollment there may be instances in which DMV’s MAU review of your DUI offense/driving history and/or court proceeding may necessitate a modification of the program type you are/were initially enrolled in. In all instances, you are financially responsible for all DUI program services received and/or incurred during your enrollment in a DUI program. (Additional program service fees are identified in the participant contract you will review and sign at the time of DUI program enrollment)

The following consent/agreement and required enrollment documents must be completed and placed in your participant file as required by CCR, Title 9 requirements. As with all documents produced during your DUI program enrollment and participation, you are encouraged to retain copies for your records.

Informed Consent and Agreement
Participant Information
Participant Name (Print)*
Enrollment*

Pre ConvictionPost Conviction
Address (City, State, Zip)*
Phone Number*
Driver License Number / X Number*
Agreement
*I verify I have read and understand the information provided to me on the Informed Consent and Agreement document regarding my DUI program enrollment. I am aware in some instances the DMV- MAU or court may later amend my program service type and in all cases, I am financially responsible for all DUI program services received.
Initial* A "Transfer In" fee in the amount of $100.00 may incur if a modification of the program type you are/were initially enrolled in changes.
Participant Signature*

Clear
Date*

MonthDayYear
Date

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS
I, Name* hereby authorize Jackson-Bibby Awareness Group to disclose information and records pertaining to my participation in the program to the following:
- The Department of Motor Vehicles.
- The Department of Healthcare Services.
- The County Offices of Alcohol and Drug Abuse Services.
- The appropriate branches of the Judicial System.
- My personal attorney.
- My personal physician.
The disclosure of information and/or records herein authorized is required for the purpose of establishing or determining my status, progress, and/or compliance with the terms and conditions of my participation in the program. Such disclosure shall be limited to information and/or records in regard to my progress and participation in the program.

I understand that this authorization can be revoked by the undersigned at any time except to the extent that action has been taken in reliance thereon. If not earlier revoked, it shall terminate ninety (90) days after my participation in the program has ended. I also understand that despite the codes (California Civil Codes 56.11 and 56.15, and Federal Regulation CFR Section 2.31), confidential information and/or records may be disclosed without my authorization pursuant to state and federal law in the following circumstances:
- Pursuant to a proper subpoena or court order.
- Reporting child abuse or elder abuse.
- Reporting an individual who is a danger to him/herself or a third party.
- Reporting the intent to commit a crime on program premises or against program staff.
A photocopy, facsimile or duplicate copy of this authorization shall be as valid as the original.
Signature*

Clear
Date*

MonthDayYear
Date
I,   Full Name*   also hereby authorize Jackson-Bibby Awareness Group , to disclose information to my designated representative:

Name: Name* Relationship:   Relationship*  Phone:      Phone Number*

Such information shall be limited to information relating to payment, scheduling and in the case of emergencies, for the purpose of facilitating treatment. This authorization is guided by the same California Codes and Federal Regulations stated above will terminate at the same time.
Signature Of Participant*

Clear
Date*

MonthDayYear
Date

Virtual Services Agreement
Dear Client,

As you are aware, the Novel Coronavirus (COVID-19) has impacted the daily lives of all Californians. All schools and some businesses are closed with more being affected every day. The latest direction from the Department of Health Care Services (DHCS) allows for the provision of temporary Remote Client Services also known as Telehealth.

To avoid a delay in completing your DUI Program, Jackson-Bibby Awareness Group, Inc. will begin offering Remote Client Services on April 6th, 2020.

Remote Client Services will enable you to continue your DUI classes with a certified counselor via a the Zoom virtual meeting platform temporarily during the COVID-19 crisis. To participate in Remote Client Services, you must:
- Register in advance for the session via an email link that will be sent to you in advance of the scheduled session.
- To receive credit for the session, you must:
• Register with your full name as provided to us at Enrollment. Credit will not be given if any aliases or other screen names are input into Zoom.

• Make sure you have paid for your virtual session in advance. Payment of credit card or debit card is only accepted at this time and payments can be made over the phone in advance.

• Be In the virtual meeting at the provided start time. It is recommended that arrive at least 5 minutes early so that you can make sure the program is downloaded and all speakers and microphones are working.

• Attend the session in a private room, free of distractions.

• Stay for the entire session and participate when called upon.

• Not be under the influence of alcohol or other drugs during the session. This is up to the counselor’s and administrators discretion.

Certain technology is required to participate in this program. You must have either a computer, tablet, or phone with a working microphone, speakers, and a camera (for video meetings). You must also be able to download the free Zoom software onto a computer or download the Zoom application on a tablet or phone.

To take advantage of this unique opportunity and keep your DUI treatment program on track, read the privacy policy on the next page and sign where indicated. Return the signed page via email the email option listed above. If you have any questions, please email or contact your program location’s manager.

I have read and agree to Jackson-Bibby Awareness Group, Inc’s Telehealth Policy.
Name – Printed*
Date*

MonthDayYear
Date
Current Email Address*
example@example.com
Name – Signature*

Clear
Date*

MonthDayYear
Date

Privacy Policy for Remote Client Services
Jackson-Bibby Awareness Group, Inc. will provide Remote Client Services (Telehealth) utilizing the Zoom Virtual Meeting Platform. To participate in Zoom meetings, you must read and agree to Zoom’s Privacy Policy.

Jackson-Bibby Awareness Group, Inc will continue to maintain confidentiality as stated in our Confidentiality Policy. Client’s will also be held to the Confidentiality Agreement signed upon enrollment.

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Remote Client Services Release
I (print your name) Name* agree to participate in temporary Remote Client Services (Telehealth) at Jackson-Bibby Awareness Group, Inc. I understand that specific technology is required to participate, and I certify that I have access to the required technology. Additionally, I have read and understand the Zoom privacy policy. I understand that Remote Client Services are being offered on a temporary basis due to the Coronavirus (COVID-19) pandemic, and that once the threat is eliminated, client services will then be available at the DUI Program location only. To receive credit for the session, I understand that I must adhere to the policies outlined in the Telehealth Client Agreement.

I understand that fees for DUI Program services will apply during this time, and that Jackson-Bibby Awareness Group, Inc. will provide me with alternate payment options and methods during the Remote Client Services time period.

I have read and agree to Jackson-Bibby Awareness Group, Inc and Zoom’s Privacy Policy.
Name – Printed*
Date*

MonthDayYear
Date
Name – Signature*

Clear
Date*

MonthDayYear
Date

Client Email/Texting Informed Consent Form
1) Risk of using email/texting

a) The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks:

b) Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

c) Email and text senders can easily misaddress an email or text and send the information to an undesired recipient.

d) Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.

e) Employers and on-line services have a right to inspect emails sent through their company systems.

f)Emails and texts can be intercepted, altered, forwarded or used without authorization ordetection.

g) Email and texts can be used as evidence in court.

h) Emails and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party.

2) Conditions for the use of email and texts The provider cannot guarantee but will use reasonable means to maintain security and confidentiality of email and text information sent and received. The provider is not liable for improper disclosure of confidential information that is not caused by provider intentional misconduct. Clients must acknowledge and consent to the following conditions:

a) Email and texting is not appropriate for urgent or emergency situations. Provider cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.

b) Email and texts should be concise. The client should call and/or schedule an appointment to discuss complex and/or sensitive situations.

c) All email can be printed and filed into the client’s record. Texts may be printed and filed as well.

d) Provider will not forward client’s identifiable emails and/or texts without the client’s written consent, except as authorized by law.

e) Clients should not use email or texts for communication of sensitive medical information.

f)Provider is not liable for breaches of confidentiality caused by the client or any third party.

g) It is the client’s responsibility to follow up and/or schedule an appointment if warranted.
Client Acknowledgement and Agreement
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email and/or texts between Jackson-Bibby Awareness Group, Inc (provider) and me, and consent to the conditions and instructions outlined, as well as any other instructions that the provider may impose to communicate with me by email or text.
Client name:*
Client signature:*

Clear
Date:*

MonthDayYear
Date
Email Address:*
example@example.com
Location*
On submitting the form, the form(s) will be emailed directly to Jackson-Bibby.
Should be Empty:

Enrollment Full Package with Virtual Services Form

PERSONAL DATA INTAKE INFORMATION FORM

IN CASE OF EMERGENCY CONTACT

Personal Information

INTAKE: Self Alcohol/Drug Assessment

SIMPLE ASSESSMENT TOOL FOR AOD ABUSE

SIMPLE ASSESSMENT TOOL FOR AOD ABUSE, PAGE 2

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Page | 2

True/False Pre/Post-Test

Driving Under the Influence (DUI) Program Enrollment Participant Information/Informed Consent and Agreement

Informed Consent and Agreement

Participant Information

Agreement

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

Virtual Services Agreement

Privacy Policy for Remote Client Services

Remote Client Services Release

Client Email/Texting Informed Consent Form

Client Acknowledgement and Agreement