EVAC INTAKE

Client Name*

First NameLast Name
Parent/Legal Guardian

First NameLast Name
Gender Identity*
Ethnicity/Race*
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Telephone Number*
Please enter a valid phone number.
Insurance Provider: *
Insurance Policy # *
Insurance Policy Start Date*

MonthDayYear
Date
Insurance Policy End Date*

MonthDayYear
Date
Services requested

Skill Building and TrainingCase ManagementSubstance Use
Referred By:

MEDICAL HISTORY QUESTIONAIRE
Are you taking any medications(prescription, over the counter vitamins, homeopathic or naturopathic remedies,traditional or alternative medicine remedies, herbs)?

YesNo
List the medication that you are currently taking for medical or behavioral health concerns below:
Name of Medication
Dosage
Frequency
Duration
Prescriber
Name of Medication
Dosage
Frequency
Duration
Prescriber
Name of Medication
Dosage
Frequency
Duration
Prescriber
Name of Medication
Dosage
Frequency
Duration
Prescriber
Are you allergic to any medications?

YesNo
Which ones?
Do you have any allergies?

YesNo
Explain?
Who is your primary care physician
When was the last time you saw your primary care physician

MonthDayYear
Date
Are you currently pregnant?

YesNoN/A

CLIENT RIGHTS
To be treated with respect and dignity to be informed of the client's rights and responsibilities at the time of admission or within 24 hours of admission
- To have your privacy protected and kept confidential
- To develop a plan of care with services to meet your needs
- To participate in decisions regarding care
- To request information about names, locations, phones, and language for local agencies
- To receive the amount and duration of services you need
- To be free from use of seclusion or restraints
- To understand available treatment options and alternatives
- To refuse any proposed treatment
- To receive care that does not discriminate against you (e.g. age, race, type of illness)
- To be free of any neglect, abuse, sexual or financial exploitation or harassment
- To receive any explanation of all medications prescribed and possible side effects
- To receive treatment, including access to medical care and habilitation, regardless of age, sexual identity, degree of MH/DD/SA disability
- To file a request for an administrative (fair) hearing
- To participate or refuse to participate in research
- To request and receive a copy of your medical records and ask for changes.
- To receive a copy of the program rules and regulations at admission
Client Signature

Clear
LegalGuardian Signature (if applicable)

Clear
Date

MonthDayYear
Date

CLIENT CHOICE FORM
The provider I choose is EASTERN VIRGINIA ADVANCE CARE, LLC

I have been made aware that there are many choices regarding a provider for mental health services and have chosen EASTERN VIRGINIA ADVANCE CARE, LLC as the provider I would like to render these services for myself and/or my family.

By signing below, I acknowledge that I freely choose to receive services from the above-mentioned provider and if I am currently receiving services from a behavioral health agency, it is my responsibility to inform them.
Client Signature

Clear
Legal Guardian Signature (if applicable)

Clear
Date

MonthDayYear
Date

CONSENT FOR TREATMENT
Client and/or Guardian of client give consent to EASTERN VIRGINIA ADVANCE CARE, LLC and its staff to provide mental health services

I authorize the collection of necessary administrative dates regarding me. I understand that such

data shall be computerized for statistical, programming, and billing purposes.

I understand information regarding me shall be collect responsibility and maintained in a

confidential clinical record. Any such records or information shall remain confidential except in
the following incidences:

Information required by third party payers and parties giving EASTERN VIRGINIA ADVANCE CARE, LLC authorization to provide said services shall be forwarded to them.

Records shall be open to EASTERN VIRGINIA ADVANCE CARE, LLC staff as needed and to appropriate state mental health officials.

Information may be exchanged if I sign a written release form indicating the nature of information to be released.

Information, which indicates a severe threat to the life or safety or another person or to self, shall be forwarded to the threatened parties or appropriate agencies to the extent necessary to protect life and safety.

Information will be released if required under a court subpoena.

Suspected abuse or neglect shall be reported to Protective Services as mandated by the Code of Texas and Federal Law.

State and Federal law prohibits the disclosure of any information identifying a Recipient as

receiving alcohol/drug services unless the Recipient consents in writing, the disclosure is allowed by court order, disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluations.

Federal Law does not protect any information about a crime committed by a Recipient either at the program or against any person who works for the program or about any threat to commit

such a crime.

I understand that all services will be provided regardless of gender, color, national origin, sexual

orientation, religious preference, and a level of disability.

If there is a medical or psychiatric emergency, I give permission for staff to seek emergency care

on my behalf.

EASTERN VIRGINIA ADVANCE CARE, LLC may share information with my consent with other associated facilities such as group homes, Dept. of Social Services, Court Services, and Area Programs if a Recipient is seen in two or more of these agencies.

I agree to satisfy my financial obligation. I understand payment is due at the time services are rendered unless payment arrangements are made.

You have the right to accept or refuse any medication, procedure test or treatment. Exception to
this right is when there is an emergency, court order or if the recipient is under 18 years old and
his/her parent or guardian has given permission.

I understand that I will be receiving the following services provided by EASTERN VIRGINIA ADVANCE CARE, LLC:

Assessment/Re-Assessment

Outpatient Therapy

Skill Building and Training

Medication Management

Case Management
Client Signature

Clear
Legal Guardian Signature (if applicable)

Clear
Date

MonthDayYear
Date
This Consent shall be valid for one year from the signature date of this form.

INFORMED CONSENT FOR TELE-SERVICES
Tele-services involves the use of electronic communications to enable health care providers at to provide services to the client for the purpose of improving client care. The information may be used for diagnosis, therapy, follow-up and/or education. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

More efficient evaluation and management.

Possible Risks:

In very rare instances, security protocols could fail, causing a breach of privacy of personal
medical information.

By signing this form, I understand the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information

also apply to telemedicine, and that no information obtained in the use of telemedicine which
identifies me will be disclosed to researchers or other entities without my consent.

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

3. I understand that I have the right to inspect all information obtained and recorded in the

course of a telemedicine interaction and may receive copies of this information for a
reasonable fee.

Consent To The Use of Telemedicine

I have read and understand the information provided and all of my questions have been answered to my satisfaction. I give my informed consent for the use of tele-services in my care.
Client Signature

Clear
Legal Guardian Signature (if applicable)

Clear
Date

MonthDayYear
Date

CLIENT LIMITED RELEASE OF INFORMATION
I understand that EASTERN VIRGINIA ADVANCE CARE, LLC has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allowEASTERN VIRGINIA ADVANCE CARE, LLC to release some of my personal information to certain individuals or agencies.

I authorize EASTERN VIRGINIA ADVANCE CARE, LLC to share the following specific information with

Who I want to have my information?

What information I want to share (be specific)

I understand:

That I do not have to sign a release form. I do not have to allow EASTERN VIRGINIA ADVANCE CARE, LLC to share my information. Signing a release form is completely voluntary. That this release is limited to what I write above. If I would like EASTERN VIRGINIA ADVANCE CARE, LLC to release information about me in the future, I will need to sign another written, time-limited release.

That releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from EASTERN VIRGINIA ADVANCE CARE, LLC.

That EASTERN VIRGINIA ADVANCE CARE, LLC and I may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share it with others.

This release expires 12 months from signature date

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Client Signature

Clear
Legal Guardian Signature (if applicable)

Clear
Date

MonthDayYear

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby give my consent for EASTERN VIRGINIA ADVANCE CARE, LLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations. (The Notice of Privacy Practices provided by EASTERN VIRGINIA ADVANCE CARE, LLC describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent.

EASTERN VIRGINIA ADVANCE CARE, LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to EASTERN VIRGINIA ADVANCE CARE, LLC

With this consent, EASTERN VIRGINIA ADVANCE CARE, LLC may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, EASTERN VIRGINIA ADVANCE CARE, LLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, EASTERN VIRGINIA ADVANCE CARE, LLC may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that EASTERN VIRGINIA ADVANCE CARE, LLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow EASTERN VIRGINIA ADVANCE CARE, LLCto use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, EASTERN VIRGINIA ADVANCE CARE, LLC may decline to provide treatment to me.
Client Signature

Clear
Legal Guardian Signature (if applicable)

Clear
Date

MonthDayYear

CONSENT FOR TRANSPORTATION
I have read and understand the transportation rules listed below and I hereby voluntarily give consent for transportation by EASTERN VIRGINIA ADVANCE CARE, LLC staff members.

Transportation Guidelines/Rules:
- Client or legally responsible person must read and sign Consent for
  Transportation prior to receiving services or transportation being rendered.
- No weapons, drugs, alcohol or smoking, use of profanity, inappropriately touching anyone,
  leaving trash in the vehicle or throwing objects from the windows.
- Hands and objects are to stay inside and windows and doors are to remain
  closed unless driver gives permission to open.
- Do not exit the vehicle until the driver gives permission.
- Seat belts are to be worn at all times.
- The appropriate child restraint device/procedures will be used in accordance with Texas State law.
My signature below indicates that I have read and understand this transportation policy and consent.
Client Signature

Clear
Legal Guardian Signature (if applicable)

Clear
Date

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES
The provider I choose is EASTERN VIRGINIA ADVANCE CARE, LLC

I have been made aware that there are many choices regarding a provider for mental health services and have chosen EASTERN VIRGINIA ADVANCE CARE, LLC as the provider I would like to render these services for myself and/or my family.

By signing below, I acknowledge that I freely choose to receive services from the above-mentioned provider and if I am currently receiving services from a behavioral health agency, it is my responsibility to inform them.
Client Signature

Clear
Legal Guardian Signature (if applicable)

Clear
Date

MonthDayYear
Date
Date

MonthDayYear
Should be Empty:

MEDICAL HISTORY QUESTIONAIRE

CLIENT RIGHTS

CLIENT CHOICE FORM

CONSENT FOR TREATMENT

INFORMED CONSENT FOR TELE-SERVICES

CLIENT LIMITED RELEASE OF INFORMATION

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

CONSENT FOR TRANSPORTATION

NOTICE OF PRIVACY PRACTICES