SPADE Program

Introduction

"Opening the door to free opportunity"

The Student Preparatory Athletic Development Enrichment Program (S.P.A.D.E) is a non-profit

organization that provides service learning, youth development and skill acquisition through several different modalities, which have a common goal to "open the door to free opportunity" for youth no matter what their social and emotional skill level at the time of referral.

The S.P.A.D.E Program provides each individual with a well-defined wraparound service plan which will consist of a program curriculum geared to promote individual progression based on the level at which they enter the program.

The S.P.A.D.E Program is motivated by the success rate of each youth participant and measures the progression of each participant with the intent to provide quality services and help achieve immaculate results.

Our Mission

Our mission is to provide high quality services and programming focused on the needs of our youth participants and their families in a safe, caring and structured environment. The S.P.A.D.E Program will promote and model opportunities for self-progression, academic independence, and social awareness and economic growth through skill acquisition and intense academic preparation to prepare our youth for a future of greatness.

Our Vision

To promper individual growth and success based on respect and caring which empowers our youth to reach their maximum potential in order to ensure a better quality of life filled with purpose and direction.

Our Philosophy

The S.P.A.D.E PROGRAM was designed to instill a sense of achievement, to encourage self-motivation and determination, to teach problem solving and decision-making skills, to reinforce a sense of responsibility and service, to emphasize the strengthening of interpersonal and family relationships, and to promote a clear understanding of moral and ethical values needed to be successful citizens within societal standards.

Individual Youth Profile Assessment

Once referred, each youth participant will undergo an Individual Youth Profile Assessment, which will aim to provide each participant with an overall idea of what the participant's strengths and weakness are. This assessment will be the blueprint for creating and implementing the Individual Success Plan. The assessment will consist of a number of questions which will probe the youth participant's knowledge of social skills, Anti Emotional behavioral management, job skills, social skills, leisure awareness, and recreational interests and hobbies.

Individual Success Plan

Once the Individual Youth Profile' Assessment is completed the S.P.A.D.E Program along with the youth participant will devise an Individual Success Plan which provides a schedule of recommended programs offered within the multi-Purpose Center and a list of specified goals and objectives which will need to be successfully reached before completion of the program. This individualized plan is an integral part of each youth participant's successful transition out of the program and into the community as it serves as the script that must be mastered in order to ensure success independent from the program and its services once completed.

Release and Waiver of Liability

 

The S.P.A.D.E Program, and its affiliates collectively, the "Program") promote, organize, and sponsor fitness activities, however, the Program does not assume any responsibility or undertake any duty of care of the health and safety of any participants.

 have registered voluntarily to engage in exercise and fitness activities, use exercise.

Equipment and/or use other facilities, available at the S.P.A.D.E Program.

I understand that the S.P.A.D.E Program involves strenuous physical exertion and will always require sound judgment during my participation. I understand that by participating I am at risk to suffer serious physical injury and possibly death. I understand and agree that I, alone, am responsible for determining my physical and mental fitness and my suitability to participate. I acknowledge that the

Program will not attempt to determine, nor will hold the Program liable to determine my physical and mental fitness, suitability, or capability to participate either before I begin participation or that the time during my participation in the fitness classes.

I understand and agree that if I, alone, chose to waive the compulsory fitness evaluation and/or the physician medical certification required of participants of the Program, that I am responsible for my decision and will not attempt to hold the Program liable for any physical injury or death arising out of or relating to my participation in, or during travel related to, S.P.A.D.E Program training.

In consideration for the work performed by the Program in promoting and organizing the S.P.A.D.E

Program fitness training, from which I receive value and benefit. I assume all risks of injury or death related to participation. | further release the Program and all of its affiliated entities, and I waive any claim that I might make against the Program and its affiliate entities, for and physical injury or death arising out of or relating to my participation in, or during travel related to S.P.A.D.E Program training.

I understand and agree that the effect of signing this Release and Waiver of Liability is to give up all of my legal rights to file any lawsuit or to recover any money damages against the Program and its affiliated entities for any claim relating the S.P.A.D.E Program training classes.

Because participation in the Program is voluntary, I have agreed to sign this Release and Waiver of Liability. I have been given the opportunity to read carefully all of the terms of this Release and Waiver of Liability and I understand fully the legal consequences of signing it.

I understand I will not be allowed to participate in the S.P.A.D.E Program unless I sign this Release and Waiver of Liability. I agree to this because I choose to participate in the S.P.A.D.E Program at my own risk, knowing that I have no legal right to seek recovery of damages or otherwise to make any claim against the Program for any harm or injury, including death that I may suffer because of my participation.

 

 

 

 

Telehealth Services Informed Consent

 

Definition of Telehealth

Telehealth involves the use of electronic communications to enable professionals to connect with inc using interactive video and audio communications. Telehealth includes the practice of psychological delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medi-clinical data.

 I understand that I have the rights with respect to telehealth:

1.   I understand privacy and the confidentiality laws apply to telehealth, and that no information obt through the use of telehealth services will be disclosed to researchers or other entities without my consent.

 

2.   My health care provider has explained how the video conferercing technology will be used to cor telehealth session, that unlike a direct patient/provider in person, I will not be in the same room a care provider.

3.    I understand the potential risks to technology including interruptions, unauthorized access and technical difficulties. I understand my health care provider or I can discontinue the videoconference consult/visit if it is believed videoconferencing technologies are not adequate for the situation.

4.   I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

5.   I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other ares, including out of state.

6.  I understand that no results for anticipated benefits can be guaranteed or assured by my provider.

 

7.  I understand my healthcare information may be shared with other individuals for purposes of scheduling and billing. Individuals other than my healthcare provider may be present during the session in order to operate videoconferencing equipment. I further understand that I will be informed of their presence, and the individuals will maintain confidentiality on information obtained during the session. Furthermore the right to request the following: ask non-medical personnel to leave the telehealth examination room; and/or terminate the consultation at any time

 8. I agree certain situations such as emergencies and crisis -- are inappropriate for  audio-/video-/computer based psychotherapy services. If I am in crisis or in an emergency, I should       immediately call 911 or seek help from a hospital crisis-oriented healthcare facility in my immediate area.

 Consent to The Use of Telehealth

By signing this form, I certify;

That I have read or had this form read and/or had this form explained to me.

That I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given ample opportunity to ask questions and that any questions have been a   my satisfaction.

 

 

 

 

Record Release Authorization

 

FOR THE RELEASE OF PROTECTED MENTAL HEALTH INFORMATION

By signing this form, confidential psychological and psychiatric Information can be released to and/or discussed with the people or agencies listed below unless noted by exclusions or limitations.

This form is signed voluntarily and may be revoked at any time. Al disclosures made pursuant to this form are valid as long as they were made before the date of revocation.

1.     I authorize my provider to: Release

2.     Second Party

Name: S.P.A.D.E Program

Address: 1410 Crain Hwy N. Suite 9B, Glen Burnie, MD 21061

Office Number: (443) 267-2844

Fax Number: (443) 354-3613

 3. Type of Information to be disclosed I authorize only the disclosure of the following

information:

 4. Purpose My health information is being disclosed at my request

or at the request of my personal representative; or

 I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not

dependent on my signing this authorization. By signing below, I acknowledge that I have read and understand this document and that I have voluntarily given my provider authorization to disclose my records.

 I understand that I may revoke this authorization at any time by providing a written notice to my

provider, however, the revocation will not have an effect on any actions taken prior to the date my revocation is received. I understand that my information may be redisclosed by the authorized person/organization receiving the information, and at that point, the information may no longer be protected under the terms of this agreement. This authorization will expire one year following the date signed unless revoked in writing.

 

 

 

 

 

 

 

 

 

Authorization to Bill Insurance

 I, the undersigned, hereby certify and attest that I have sought evaluation, treatment, or medical advice from the staff at the clinic named above. I therefore authorize the medical staff and personnel to release my minor child's medical information to the insurance company listed above for the purpose of determining and receiving benefits for medical bills.

 

I understand and acknowledge that the medical staff will submit my claim to the insurance company on my behalf. I further understand that I will be held responsible for any amount of my medical bills not covered by my insurance policy or claims, and that I will be responsible for paying all deductibles, fees, copayments, and co-insurance payments required.

 

I understand that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided above. Non-compliance or defaulting on payments may result in denial of service and/or a legal claim against me for non-payment.

 

 

 

 

 

 

 

 

 

Acknowledgments

 Please read and Sign below the following indicating your agreement. Your signature indicate you read and understand your agreement.

___ I have read and fully understand the S.P.A.D.E Program.

___ I understand that I may be required to provide a physician's clearance in order to participate in an exercise program.

___I understand and agree that the S.P.A.D.E Program will not have or assume any financial responsibility or liability for the expense of medical treatment or compensation for any

injury I may sustain during or result from participating in the program.

___I understand that I am responsible for my own actions whether supervised or unsupervised by the S.P.A.D.E Program staff.

___ I acknowledge that the S.P.A.D.E Program shall not be responsible or liable to members for loss or damage to articles/property lost or stolen at the center including their automobiles and the contents thereof.

___ In consideration of the benefits and other activities of the S.P.A.D.E Program, I apply for membership to begin on intake date provided.

 

 

 

 

 

Notice of Privacy Practices

Effective April 29, 2015

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. Your health record contains personal information about you and your health. This information about you

that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"), This Notice of Privacy Practices describes how your provider may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI.

Under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), your provider is required to maintain the privacy of PHI and to provide you with notice of his or her legal duties and privacy practices with respect to PHI. Your provider is required to abide by the terms of this Notice of Privacy Practices.

Your provider reserves the right to change the terms of this Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that your provider maintains at that time. Your provider will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or by providing one to you at your next appointment.

HOW YOUR PROVIDER MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose. of providing, coordinating, or managing your healthcare teatment and related services. This includes consultation with clinical supervisors or other treatment team members, your provider may disclose PHI to any other consultant only with your authorization.

For Payment: Your provider may use and disclose PHI so that he or she can receive payment for the treatment services provided to you. Examples of payment-related activities are making a determination of „eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing. services provided to you to determine medical necessity or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, only disclose the minimum amount of PHI necessary for purposes of collection will be disclosed.

For Health Care Operations: Your provider may use or disclose, as needed, your PHI in order to support his or business activities including, but not limited to, quality assessment activities, licensing and conducting or arranging other business activities. For example, your PHI may be shared with third parties that perform various business activities provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. Your PHI may be used to contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services.

Required by Law: Under the law, your provider must make disclosures of your PHI to you upon your request In addition, disclosures must be made to the Secretary of the Department of Health and Hunan Services for the purpose of investigating or determining compliance with the requirements of the Privacy Rule.

Without Authorization: Applicable law and ethical standards permit your provider to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

Required by Law, such as the mandatory reporting of child abuse or neglect or elder abuse, or

Req mandatory government agency audits or investigations Required by Court Order

Necessary to prevent or lessen a serious an imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission: Your provider may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI maintained about you. To exercise any of these rights, please submit your request in writing to your provider.

Right of Access to Inspect and Copy. In most cases, you have the right to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. Your provider may charge a reasonable. cost-based fee for copies

Right to Amend. If you feel that the PHI your provider has about you is incorrect or incomplete, you may ask for it to be amended, although your provider is not required to agree to the amendment.

Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures that your provider makes of your PHI. Your provider may charge you a reasonable fee if you request more than one accounting in any 12-month period.

Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or healthcare operations. Your provider is not required to agree to your request.

Right to Request Confidential Communication. You have the right to request that your provider communicate with you about medical matters in a certain way or at a certain location.

Right to a Copy of This Notice. You may ask your provider for a paper copy of this notice at any time.

 COMPLAINTS If you believe your privacy rights have been violated, you may submit a complaint to the Federal Government.

Filing a complaint will not affect your right to further treatment or future treatment.

To file a complaint with the Federal Government, contact.

 Secretary of the U.S. Department of Health and Human Services

200 Independence Avenue, SW

Washington, DC 20201

(202) 619-0257

 ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge receipt of the Notice of Privacy Practices, which explains my rights and the limits on ways my provider may use or disclose personal health information to provide service.

 

  

 

Informed Consent for Assessment and Treatment

 I understand that I am eligible to receive a range of services from my provider. The type and extent of services that I receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

 

l understand that I have the right to ask questions throughout the course of treatment and may request an outside consultation. (I also understand that my provider may provide me with additional information about specific treatment issues and treatment methods on an as-needed basis during the course of treatment and that I have the right to consent to or refuse such treatment).

I understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment and in the review process. No promises have been made as to the results of this treatment or of any procedures utilized within it. I further understand that I may stop treatment at any time, but agree to discuss this decision first with my provider.

 

l am aware that I must authorize my provider, in writing, to release information about my treatment but that confidentiality can be broken under certain circumstances of danger to myself or others. I understand that once information is released to insurance companies or any other third party, that my provider cannot guarantee that it will remain confidential. When consent is provided for services, all information is kept confidential, except in the following circumstances:

 

When there is risk of imminent danger to myself or to another person, my provider is ethically bound to take necessary steps to prevent such danger. When there is suspicion that a child or elder is being sexually or physically abused, or is at risk of such abuse, my provider is legally required to take steps to protect the child, and to inform the proper authorities.

 

When a valid court order is issued for medical records, my provider is bound by law to comply with such requests. While this summary is designed to provide an overview of confidentiality and its limits, it is important that you read the Notice of Privacy Practices which was provided to you for more detailed explanations and discuss with your provider any questions or concerns you may have.

 

By my signature below, I voluntarily request and consent to behavioral health assessment, care, treatment, or services and authorize my provider to provide such care, treatment or services as are considered necessary and advisable. I understand the practice or behavioral health treatment is not an exact science and acknowledge that no one has made guarantees or promises as to the results that I may receive.

By signing this Informed Consent to Treatment Form, I acknowledge that I have both read and understood the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

 

 

 

 

 

 

 

Video Consent and Release Form

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to _Renew/SPADE PRO, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet).

This consent includes, but is not limited to: 

_ - (a) Permission to interview, film; photograph, tape, or otherwise make a _ video reproduction of me and/or record my voice;

_ - (b) Permission to use my name; and

_ - (c) P.ermission to use quotes from the interview(s) (or excerpts of such quotes, the film photographs, tapes, reporduction of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines, and other print media, on televison, adio and electronic media (including internet), in theatrical media and/or in mailings for edicational and awareness.

This consent is given in perpetuity, and does not require prior approval by me.

 

 

 

 

 

 

 

Transportation Consent

 

I give my child permission to Ride with Renew/Spade PRO driving Staffing to:

1410 N Crain Hwy Suite 9B Glen Burnie MD 21061

400 Luzerne Rd Baltimore MD 

I understand that riding to and from the group is a privilege and can be revoke at any time due to child misconduct.