Restore Intake Paperwork

Restore Program

Participation Agreement & Consent for Services
Completing this form does not finalize your registration for the Restore program. You will be required to submit a copy of your ID and your court order for programming as well as making a payment for the program fee. Documents can be submitted as part of this form or they can be dropped off at our office at 1325 Sycamore Rd., DeKalb, IL. Once all intake paperwork, documents, and payment are received, you will need to visit our office to pick up your program booklet that will be used throughout the 10 weeks.

The program coordinator will reach out once this intake is received to outline any outstanding documents and review next steps.

Welcome to Family Service Agency's Center for Counselling Restore program. The Center for Counselling provides services for all ages through a staff of experienced, diverse licensed counselors, social workers, and marriage/family therapists. The Restore program is offered virtually on Wednesday evenings from 6:00-7:00PM, or Thursday evening from 7:00-8:00PM.
- If you are unable to attend a session, please call the agency at (815) 758-8616 to reschedule
- If you CANCEL a session less than 24 hours before the class or are a NO SHOW (DO NOT LOGIN), you will be assessed a $25 re-scheduling fee.
The expectations of the Family Service Agency Restore program are:
- Pre-registration and scheduling is required to attend the 10 group educational programming sessions at the cost of $800. Payments can be made upfront in the amount of $800, or $400 can be paid at the first two sessions ($400 before the first session, $400 before the second session).
- Abstinence from drugs and alcohol is required during the Restore program. A random observed urine screening at an official drug screening facility will be completed during the educational programming. The date that your drug screening letter will be sent to you is randomly selected.
- You must attend and participate in the 10-step group sessions. You are provided with a workbook which you must bring to all group sessions.
- You must call Family Service Agency at (815) 758-8616 if you are unable to log in due to an emergent situation. If you miss ONE group session, you MUST retake this session when it is available. TWO or more missed group sessions may result in immediate termination from the program.
- Courteous behavior is expected. Disruptive individuals will be removed from the virtual class, forfeit the registration fee, and will be required to complete the program through a different agency-you will not be permitted to re-enroll.
- Cell phone use or other recording devices are prohibited during the program.
- Restore is a program for adults. Children should not be part of the virtual online class.
- Please login 5-15 minutes prior to the session to adjust for any technical difficulties. If you attempt to join the class after 6:05PM (Wedneday sessions) or 7:05PM (Thursday sessions), you will not be allowed to enter the session and will need to reschedule for a different date. A re-scheduling fee is applicable.
The following events will be treated as infractions of the Restore program resulting in termination without reimbursement:
- Missed treatment appointments-clients may be terminated from the program if 2 or more sessions are missed
- Missed court appearances
- Refusal or failure to complete a urine drug screening by your given deadline
- Infraction of rules of treatment including verbal threat of violence
- Other noncompliance with treatment plan
- Abuse of drugs and/or alcohol
- New criminal offenses
To receive the certificate of completion, you must:
- Attend each session in its entirety. Equipment camera MUST be turned on at all times to confirm attendance throughout.
- Provide your court case number at registration
- Must pay the program fee of $800 at the time of registration OR $400 at the time of the first session and second session. Personal checks will not be accepted. Payment can be made with cash, Visa, MasterCard, or Discover.

Consent for Services
I, Client Name*, request services from Family Service Agency's Programs:
- I seek and consent to participate in services through Family Service Agency's programs.
- I understand that I may stop program services at any time and that I am responsible for any consequences of terminating services.
- I understand and have discussed with my group facilitator: a.) my condition, problem and/or diagnosis, confidentiality and the limits or exceptions of confidentiality.
Agreement to Pay for Professional Services
I, Client Name*, agree to pay the program fee described above for these services and any additional fees described below.
Additional charges may apply:
- If I fail to cancel an appointment less than 24 hours in advance or no show a scheduled session, I will be charged a $25 fee.
- A $20 fee may be applied for a replacement workbook if your is lost.
Additional billing policies:
- Program costs and any incurred fees are out of pocket expenses.
- If a bill is not paid it may be sent to collections and the client will be responsible for the additional 35% charged by the collection agency to collect the bill.
- I am responsible for providing Family Service Agency with an updated address and contact information. Failure to do so may result in any unpaid bill being sent to collections.
- Lack of payment of the sessions may result in being unable to schedule another appointment/session.
- Any billing questions should be directed to the Family Service Agency Business Office.
We will work with you to successfully complete the Restore program and gain back your life management. If you have additional concerns, please contact the Agency for assistance at (815) 758-8616.

My signature indicated understanding of the expectations for Family Service Agency's Restore program and my agreement to comply with the expectations and billing policies as stated above.

I understand and agree to the information contained in the Program Services and give informed and willing consent to receive these services from Family Service Agency for myself.
Client Name:*

First NameLast Name
Client Signature:*

Powered by Jotform SignClear

Adult Intake Form
Client Name:*

First NameLast Name
Preferred Name:
Preferred Pronouns
Client Date of Birth*
Social Security Number:
Phone Number:*
Please enter a valid phone number.
Phone type:*

Home PhoneCell Phone
Email:*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:
Employer Phone Number:
Please enter a valid phone number.
Preferred Contact Method:*

Home PhoneCell PhoneWork PhoneEmail

Financial & Household Information:
What is your current employment status?*
Do you have insurance through your employer?*

YesNo
If yes, list the place of employment that your insurance is through:
Client Annual Income:*
Household Annual Income:*
Primary Insurance Company:*
Primary Insurance Policy Number:*
Primary Insurance Group Number:*
Secondary Insurance Company:
If Applicable
Secondary Insurance Policy Number:
If Applicable
Secondary Insurance Group Number:
If Applicable
Full name of insured person (if not client):
Social Security Number of insured person (if not client):
Date of Birth of insured person (if not client):
Phone Number of insured person (if not client):
Mailing Address of insured person (if not client):
Email Address of insured person (if not client):
Number of members in the household:*
Please provide the first name, last name, age, gender, and relationship to the client of all household members

Consent to Drug Testing
I, Client Name, understand that Family Service Agency requires my authorization to conduct a drug test during the Restore program. I have been informed of and understand the testing procedure.

I agree to provide any specimens needed to conduct the drug test. I understand that if I refuse to undergo the drug screening, the results will be reported to the DeKalb County Court Diversion Program which may result in termination from the program or potential court consequences for violation of Family Service Agency's Restore Program Drug Policy. This policy exempts the use of legally prescribed medication under the direction of a physician.

I have been prescribed the following medications, drugs, or substances:

	Medication/Drug Name	Dosage	Prescribing Physician
Information
Information
Information
Information

I hereby consent to undergo the 9-panel observed urine test. I authorize any physician, laboratory, hospital, and/or medical professional retained by Family Service Agency's Restore Program to conduct this drug test and to provide the results to DeKalb County Court Diversion Program. I release Family Service Agency's Restore Program and any other person or institution conducting this drug test from liability. I give this consent pursuant to all state or federal privacy statutes and waive all rights to nondisclosure of this test record and results only to the extent of the disclosures authorized in this form.
Client Name:*

First NameLast Name
Client Signature:*

Powered by Jotform SignClear

Consent to Participate in Telehealth Appointments

The Restore program offered at Family Service Agency is only offered virtually through Zoom. Your consent to participate through means of telehealth is required to enroll in the Restore program.
I, First Name* Last Name* , understand the following:
- My behavioral health professional wishes me to engage in a telehealth consultation using Zoom.
- My behavioral health professional has provided information needed to make an informed decision about engaging in Zoom technology.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
- I understand that my behavioral health professional or I can discontinue the telehealth consult/visit if it is felt that the Zoom videoconferencing connections are not adequate for the situation.
- I understand that if others are present during the consultation other than my behavioral health professional, they will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: 1.) omit specific details of my medical history/physical examination that are personally sensitive to me; 2.) ask non-medical personnel to leave the telehealth session/room: and or 3.) terminate the consultation at any time.
- In an emergency, I understand that the responsibility of my behavioral health to contact my listed emergency contact or the local first responders if there is a termination of the Zoom video conference connection.
- I have had a direct conversation with my behavioral health professional, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand.
Please indicate your preference below*

I have had the alternative to a telehealth consultation explained to me and I am choosing to participate in a Zoom telehealth consultation.I have had the alternatives to a telehealth consultation explained to me and I am choosing not to participate in a Zoom telehealth consultation.
Please indicate your preference below*

I have had the alternative to a telehealth consultation explained to me and I am choosing to participate in a Zoom telehealth consultation.I have had the alternatives to a telehealth consultation explained to me and I am choosing not to participate in a Zoom telehealth consultation.
By signing this form I certify:
- I have read or have had this form read/explained to me.
- I fully understand its contents including the risks and benefits of the procedure(s).
- I have been given ample opportunity to ask questions and that my questions have been answered to my satisfaction.
Signature*

Powered by Jotform SignClear

Authorization to Release Information

Those enrolling in the Restore program must consent to the release of certain program information to the DeKalb County State's Attorney Diversion Program. Family Service Agency will not be able to confirm your participation in the Restore program or submit a certificate of completion to the courts without your signature below.
I hereby give consent to Family Service Agency of DeKalb County [1325 Sycamore Rd., DeKalb, IL., 60115] to release and/or exchange protected mental health information and/or program information concerning the above-named client in written, oral or electronically to the following person or entity:
Agency or Individual: DeKalb County State's Attorney Diversion Program

Address: 133 W. State St., Sycamore, IL., 60178

Phone Number: (816) 895-7168

Fax Number: (815) 895-7101

Information to be released for the following purpose(s):
- Legal Use
Type of information to release:
- Treatment Plan
- Dates of Service
- Discharge Summary
- Treatment Progress/Notes
- Intake/Assessment
- Substance Abuse
I understand that:
- I have the right to obtain a copy of my own protected health information.
- I have the right to revoke this authorization at any time. I must do so in writing to the medical records department. I may not revoke information that has already been authorized and disclosed.
- Re-disclosure of information is prohibited without written consent. That being stated, Family Service Agency cannot prevent an entity to which it is disclosing to from re-disclosing the information on their own accord.
- Authorizing to disclose protected health information is voluntary and not required for treatment, payment, or benefits.
- Form must be filled out in its entirety for request to be honored.
- Fees may be charged for records per all laws applicable to release of protected health information.
- My records may contain information pertaining to Sexually Transmitted Disease (STD), Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV).
Client Signature:*

Powered by Jotform SignClear

Documentation Submission

A copy of your ID and court order for programming are needed to register for programming with our agency. You may submit copies of these documents below or you may stop by our office at 1325 Sycamore Rd., DeKalb, IL.to drop them off. Please note that if you submit the documents on this form,they will need to be legible in order to be accepted. If a document is illegible, it will not be accepted.
Client ID:

Cancelof
Court Agreement for the Restore Program:

Cancelof

Client Acknowledgements
Should be Empty:

Restore Program

Consent for Services

Agreement to Pay for Professional Services

Adult Intake Form

Demographic Information

Financial & Household Information:

Consent to Drug Testing

Consent to Participate in Telehealth Appointments

Authorization to Release Information

Documentation Submission

Client Acknowledgements