The following pages will contain these documents:

1. Emergency Contact
2. ROI
3. Bill of Rights
4. Notice of Privacy Rights & Practices
5. Client Rights and Protections 2451.12
6. Clients Rights, Protection & Grievance Policy
7. Program abuse prevention plans 
8. Right to be photographed
9. Consent form to be photographed and audio recorded
10. Demographic Information
11. Mental Health Services & Financial Agreement
12. Mental Health Cancellation Agreement
13. Telehealth Consent Form
14. Intake Forms Acknowledgement

Primary Emergency Contact: 

Secondary  Emergency Contact: 

Consent for Contact in Case of Emergency:

I authorize Roots Wellness Center to contact the individuals listed above in case of a medical or mental healthemergency. I understand that my emergency contacts may be informed of my condition if necessary to ensure my safety.

I, the undersigned, authorize the exchange of information between:

Disclosing Party:

Roots Wellness Center

1916 University Ave W

St. Paul MN, 55104

 Receiving Party:

Health information includes written and oral information. By indicating any of the categories above, you are giving permission for written information to be released and for the above ensures speaking to each other about your health information.

I understand that:

• This authorization is voluntary and not a condition of treatment.
• I may revoke this authorization at any time in writing, except to the extent that action has already been taken.
• The information disclosed may be subjectg to re-disclusure and may no longer be protected under HIPPA
• This consent will end one year from the date the form was signed unless I indicate an earlier date or event here:

Courteous treatment. Clients have the right to be treated with courtesy and respect for their individuality by employees or people providing service in a health care facility.

Appropriate health care. Clients shall have the right to appropriate medical and personal care based on individual needs.

Physician's identity. Clients shall have or be given, in writing, the name, business address, telephone number, and specialty, if any, of the physician responsible for coordination of their care. In cases where it is medically inadvisable, as documented by the attending physician in a client's care record, the information shall be given to the client's guardian or other person designated by the client as a representative.

Relationship with other health services. Clients who receive services from an outside provider are entitled, upon request, to be told the identity of the provider.

Information about treatment. Clients shall be given, by their providers, complete and current information concerning their diagnosis, treatment, alternatives, risks, and prognosis as required by the physician's legal duty to disclose. This information should be in terms and language the Clients can reasonably be expected to understand.

Clients may be accompanied by a family member or other chosen representative, or both. This information shall include the likely medical or major psychological results of the treatment and its alternatives. In cases where it is medically inadvisable, as documented by the attending provider in a client's medical record, the information shall be given to the client's guardian or other person designated by the client as a representative. Individuals have the right to refuse this information.

Participation in planning treatment; notification of family members. Clients shall have the right to participate in the planning of their health care. This right includes the opportunity to discuss treatment and alternatives with individual caregivers, the opportunity to request and participate in formal care conferences, and the right to include a family member or other chosen representative, or both. If the client cannot be present, a family member or other representative chosen by the client may be included in such conferences.

Continuity of care. Clients shall have the right to be cared for with reasonable regularity and continuity of staff assignment as far as facility policy allows.

Right to refuse care. Competent clients shall have the right to refuse treatment based on the information required in Information about treatment, and to terminate services at any time, except as otherwise provided by law or court order.

Experimental research. Written, informed consent must be obtained prior to a client's participation in experimental research. Clients have the right to refuse participation. Both consent and refusal shall be documented in the individual care record.

Freedom from maltreatment. Clients shall be free from maltreatment as defined in the Vulnerable Adults Protection Act.

"Maltreatment" means conduct described in section or the intentional and nontherapeutic infliction of physical pain or injury, or any persistent course of conduct intended to produce mental or emotional distress. Every client shall also be free from nontherapeutic chemical and physical restraints, except in fully documented emergencies, or as authorized in writing after examination by a client's physician for a specified and limited period.

Treatment privacy. Clients shall have the right to respectfulness and privacy as it relates to their medical and personal care program. Case discussion, consultation, examination, and treatment are confidential and shall be conducted discreetly. Privacy should be respected during toileting, bathing, and other activities of personal hygiene, except as needed for client safety or assistance.

Confidentiality of records. Clients shall be assured confidential treatment of their personal and medical records and may approve or refuse their release to any individual outside the facility.

Responsive service. Clients shall have the right to a prompt and reasonable response to their questions and requests.

Personal privacy. Patients and residents shall have the right to every consideration of their privacy, individuality, and cultural identity as related to their social, religious, and psychological well-being.

Grievances. Clients shall be encouraged and assisted, throughout their stay in a facility or their course of treatment, to understand and exercise their rights as clients and citizens. Clients may voice grievances and recommend changes in policies and services to facility staff and others of their choice, free from restraint, interference, coercion, discrimination, or reprisal, including threat of discharge. Notice of the grievance procedure of the facility or program, as well as addresses and telephone numbers for the Office of Health Facility Complaints.

Protection and advocacy services. Clients shall have the right of reasonable access at reasonable times to any available rights protection services and advocacy services so that the Clients may receive assistance in understanding, exercising, and protecting the rights described in this section and in other law. This right shall include the opportunity for private communication between the clients and a representative of the rights protection service or advocacy service.

Non-Discrimination. Client has the right to be free from being the object of unlawful discrimination without regard to race, color, nation of origin, language, religion, political beliefs, sex, marital status, age, sexual orientation, gender identity, or disability, including AIDS, AIDS-related complex, or status as HIV positive.

Additional Rights: Examine public data on your provider maintained by their board; Be informed of the provider's license status, education, training, and experience To have access to your records as provided in Minnesota Statutes, sections 144.291 to 144.298 To be informed of the cost of professional services before receiving the services To know the intended recipients of psychological assessment results; To withdraw consent to release assessment results, unless that right is prohibited by law or court order or is waived by prior written agreement; To a nontechnical description of assessment procedures To a nontechnical explanation and interpretation of assessment results, unless that right is prohibited by law or court order or is waived by prior written agreement.

Complaint options: 

Ombudsman for Mental Health and Developmental Disabilities Phone: 651-757-1800 or 1-800-657-3506 Email: ombudsman.mhdd@state.mn.us Mailing Address: 121 7th Place East Suite 420 Metro Square Building St. Paul, Minnesota 55101-2117	MN Board of Social Work (612) 617-2100; (888) 234-1320 2829 University Ave SE, Suite 340 Minneapolis, MN 55414-3239 Hearing/Speech Relay: (800) 627-3529 Email: social.work@state.mn.us
Office of Health Facility Complaints 651-201-4201 or 1-800-369-7994 health.ohfc-complaints@state.mn.us	MN Board of Psychology 2829 University Ave. SE, Suite 320 Minneapolis, MN 55414 Phone: (612)617-2230 Hearing/Speech Relay: (800)627-3529 Email: psychology.board@state.mn.us
MN Board of Behavioral Health and Therapy (612) 548-2177 FAX (612) 617-2187 2829 University Ave SE Suite 210 Minneapolis, MN 55414 email: bbht.board@state.mn.us	MN Board of Marriage and Family Therapy (612) 617-2220 2829 University Ave SE Suite 400 Minneapolis, MN 55414 Hearing/Speech Relay: (800) 627-3529 Email: mft.board@state.mn.us

 

 

 

 Attestation to Review and Understanding of the MN Healthcare Bill of Rights

I have received and reviewed the MN Healthcare Bill of Rights

THIS NOTICE DESCRIBES HOW YOUR PRIVATE INFORMATION, INCLUDING HEALTH INFORMATION, MAY BE USED AND DISCLOSED, AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your health record contains personal information about you and your health. This information, called Protected Health Information (PHI), includes any data that identifies you and relates to your mental and/or physical health. We are committed to safeguarding your privacy by complying with all applicable federal and state privacy laws, including the Minnesota Government Data Practices Act and the federal Health Insurance Portability and Accountability Act (HIPAA This notice explains your privacy rights, how we use your information, and when it may be disclosed.

Why We Collect Your Information

We collect private information to: Identify you and distinguish you from others with similar names. Determine your eligibility for services. Process payments from insurance or government programs. Coordinate with other healthcare providers or agencies involved in your care. Perform audits, evaluations, or research to improve our programs.

How We Use and Disclose Your Information

The following are examples of how your protected information may be used or disclosed. These examples are not exhaustive.

Treatment/Services

We may use your information to provide, coordinate, or manage your care. For example, we may consult with your primary physician or other healthcare providers to support your treatment.

Payment

We may share your information with your insurance company or other agencies to obtain payment for the services we provide. For instance, we may verify your eligibility for benefits or submit claims for reimbursement.

Healthcare and Human Services Operations

We may use your information for activities necessary to operate our organization, such as quality assessments, program evaluations, audits, licensing, and financial management.

Required by law

We will disclose your information if required by federal, state, or local law, such as to comply with public health reporting or government investigations.

Legal Proceedings

We may disclose your information in response to a court order or legal subpoena.

Your information may be shared with researchers or evaluators when permitted by law and with appropriate privacy safeguards.

Exceptions to Privacy and Confidentiality

In some situations, we may disclose your information without your authorization, including:

• If you pose a serious threat of harm to yourself or others.
• If there is suspicion of abuse or neglect of a child or vulnerable adult.
• If you are a pregnant client with exposure to certain substances (e.g., cocaine, methamphetamines, THC, or alcohol
• If required to report professional misconduct by healthcare providers.
• If subpoenaed by a court. If your legal guardian or parent requests access to your records (for minors, unless restricted by law).

Your Privacy Rights

You have several rights regarding your protected information:

• Right to Access and Copy Your Records You can inspect and obtain a copy of your records. Certain exceptions apply, such as psychotherapy notes or information prepared for legal proceedings.
• Right to Request Restrictions You may request that we limit the use or disclosure of your information. While we will consider your request, we are not required to agree if it conflicts with legal or operational requirements.
• Right to Amend Your Records If you believe your records are incorrect or incomplete, you can request an amendment. We may decline the request but will document your concerns in your record.
• Right to Request Alternate Communication You may request that we contact you using specific methods (e.g., via mail instead of phone) or at specific locations. We will accommodate reasonable requests.
• Right to an Accounting of Disclosures You can request a list of instances where we shared your information for purposes other than treatment, payment, or operations, up to six years prior to the request.

How to Ask Questions or File Complaints

If you have questions about your privacy rights or believe your rights have been violated, you can contact:

Privacy Officer: Katy Armendariz, CEO, at 612-289-5656.

Minnesota Department of Human Services, Data Privacy Office: 4th Floor, Centennial Building, St. Paul, MN 55155. Phone: 651-297-3173.

You will not face retaliation for filing a complaint.

Attestation to review and understanding of the Privacy Rights & Practices

I have received and reviewed the Privacy Rights & Practices

Subdivision 1. Client rights. A license holder must ensure that all clients have the following rights: (1) the rights listed in the health care bill of rights in section 144.651 Health Care Bill of Rights; (2) the right to be free from discrimination based on age, race, color, creed, religion, national origin, sex, gender identity, marital status, disability, sexual orientation, and status about public assistance. The license holder must follow all applicable state and federal laws including the Minnesota Human Rights Act, chapter 363A; and (3) the right to be informed prior to a photograph or audio or video recording being made of the client. The client has the right to refuse to allow any recording or photograph of the client that is not for the purposes of identification or supervision by the license holder.

Subd. 2. Restrictions to client rights. If the license holder restricts a client's rights, the license holder must document in the client file a mental health professional's approval of the restriction and the reasons for the restriction.

Subd. Notice of rights. The license holder must give a copy of the client's rights according to this section to each client on the day of the client's admission. The license holder must document that the license holder gave a copy of the client's rights to each client on the day of the client's admission according to this section. The license holder must post a copy of the client rights in an area visible or accessible to all clients. The license holder must include the client rights in Minnesota Rules, chapter 9544, for applicable clients.

Subd. 4.Client property. (a) The license holder must meet the requirements of section 245A.04, subdivision 13.

(b) If the license holder is unable to obtain a client's signature acknowledging the receipt or disbursement of the client's funds or property required by section 245A.04, subdivision 13, paragraph (c), clause (1), two staff persons must sign documentation acknowledging that the staff persons witnessed the client's receipt or disbursement of the client's funds or property. (c)The license holder must return all the client's funds and other property to the client except for the following items: (1) illicit drugs, drug paraphernalia, and drug containers that are subject to forfeiture under section 609.5316. The license holder must give illicit drugs, drug paraphernalia, and drug containers to a local law enforcement agency or destroy the items; and (2) weapons, explosives, and other property that may cause serious harm to the client or others. The license holder may give a client's weapons and explosives to a local law enforcement agency. The license holder must notify the client that a local law enforcement agency has the client's property, and that the client has the right to reclaim the property if the client has a legal right to possess the item. (d)If a client leaves the license holder's program but abandons the client's funds or property, the license holder must retain and store the client's funds or property, including medications, for a minimum of 30 days after the client's discharge from the program.

§Subd. .Client grievances. (a) The license holder must have a grievance procedure that: (1) describes to clients how the license holder will meet the requirements in this subdivision; and (2) contains the current public contact information of the Department of Human Services, Licensing Division; the Office of Ombudsman for Mental Health and Developmental Disabilities; the Department of Health, Office of Health Facilities Complaints; and all applicable health-related licensing boards. (b) On the day of each client's admission, the license holder must explain the grievance procedure to the client. (c) The license holder must: (1) post the grievance procedure in a place visible to clients and provide a copy of the grievance procedure upon request; (2) allow clients, former clients, and their authorized representatives to submit a grievance to the license holder; (3) within three business days of receiving a client's grievance, acknowledge in writing that the license holder received the client's grievance. If applicable, the license holder must include a notice of the client's separate appeal rights for a managed care organization's reduction, termination, or denial of a covered service; (4) within 15 business days of receiving a client's grievance, provide a written final response to the client's grievance containing the license holder's official response to the grievance; and (5) allow the client to bring a grievance to the person with the highest level of authority in the program.

 

Attestation to review and understanding of the Clients Rights & Protection 2451.12

I have received and reviewed the Clients Rights & Protection 2451.12

Protecting each client's rights is the responsibility of each staff member. This responsibility is primary and essential to the effective delivery of services and to client outcomes.

Each client at Roots Wellness Center has the rights identified in sections 144.651, 148F.165, 253B.03, and 254B.02, subdivision 2, and included in the paragraphs below.

Procedure: 

• Roots Wellness Center will give each client at service initiation a written statement of the client's rights and responsibilities
• The grievance procedure will be given to each client at orientation and posted in a place visible to clients and made available upon a client's or former client's request.

Grievance Procedure

Each staff member is, at some level, responsible for listening to, responding to, and assisting clients with the submission of a complaint/grievance.

The following requirements apply to all staff:

• When a client has indicated the desire to submit a complaint/grievance, and upon request, a staff member must help the client develop and process a grievance.
• The staff member will help the client document, in writing, their complaint/grievance, and ask the client to sign and date the document.
• The staff member will inform the client they will receive a written response from management within three days.
• The staff member will forward the written grievance to the treatment director or supervisor and will complete an agency Incident Report (Appendix A or Procentive document M458-1022)
• The treatment director or supervisor will provide a written response, signed, and dated, to the client within three days. This response will be documented in the incident report (Appendix A or Procentive document M458-1022 within 15 business days of receiving a client's grievance, provide a written final response to the client's grievance containing the license holder's official response to the grievance; and allow the client to bring a grievance to the person with the highest level of authority in the program.
• The Clinical Director will inform the client that, should they be unhappy with the response, they are welcome to forward the complaint/grievance to the CEO or HR Manager for further review. If the client elects to continue escalation of the complaint/grievance, they shall be advised that the CEO or HR Manager will reply in writing within three days.

Additional Contacts 

Clients can also contact one of the agencies listed below, at any time, to voice concerns or lodge complaints about the services they receive at Roots Wellness Center:

• Office of Health Facility Complaints, 85 E 7th Place, Suite 220, St. Paul MN Phone 651-215-8705 or 651-201-500 or 1-888-345-0823 Fax 651-281-9796
• Office of the Ombudsman for Mental Health and Developmental Disabilities, 121 7th Place W. Suite 420, Metro Square Building, St. Paul MN 55101, Phone 651-757-1800 or 1-800-657-3506
• Minnesota Department of Human Services - Division of Licensing; 444 Lafayette Road, St. Paul MN 55154 Phone 651-431-6500 Fax 651-431-7673
• Board of Behavioral Health and Therapy 335 Randolph Avenue, Suite 200, St. Paul, MN55102 Phone 651-201-2756 Fax 651-797-1374

Attestation to review and understanding of the RWC Client Rights, Protection & Grievance Policy

I have received and reviewed the RWC Client Rights, Protection & Grievance Policy

This plan fulfills the requirements of law and rule of Minnesota Statutes 626.557 Subd. 14 and 245A.65 Subd. 2. The program provides Children's Day Treatment/ARMHS and psychotherapy services. Most services are completed in the client's home but on occasion, clients receive services at our facility. Services are held in a portion of the Central Midway building in St. Paul, MN. The program services children ages 5 to 21 years-old, and adults of any gender from ages 18 to 80 years-old with a need for treatment mental health and everyday stability skills.

A copy of the Program Abuse Prevention Plan is prominently posted in our facilities information board visible to everyone and is reviewed with an individual's guardian or with the client if they are their own guardian within twenty-four hours of admission to the program or, for persons who are their own guardian and would benefit more from a later orientation, within seventy-two hours, and discussed to ensure the client understands it. When applicable, the person's legal representative will be notified of the orientation. The individual or guardian will receive a copy of this plan, and a copy will be kept in the client's internal file.

All clients will be assessed at the time of intake, and on an ongoing basis as needed, to determine whether they meet criteria to be classified as vulnerable adults under Minnesota Statutes 626.557 and 245A.65. If so, clients in this program participate in the development of an individual Abuse Prevention Plan to the full extent of the person's abilities, or the person's legal representative and/or guardian shall be given the opportunity to participate with or for the person in the development of the plan.

The program will identify referrals made when individuals in this program are susceptible to abuse outside the scope or control of the licensed services and promptly notify the appropriate parties involved.

Population Assessment

Age range of persons receiving services: 5 to 99 years-old

How will the program reduce the potential of abuse and/or harm to people related to the age of people receiving services?

RWC has created a system to ensure the safety of all clients served. This system includes but is not limited to:

• A risk management plan that includes an Individual Abuse Prevention Plan that assesses the level of vulnerability for each client served by the program.
• A Program Abuse Prevention Plan that is posted in visible areas.
• Frequent Quality Assurance reviews and Client experience surveys
• Comprehensive training is provided to all Practitioners and Providers who are considered a Mandated Reporter under section 626.557, who work directly or indirectly with the Client on abuse, neglect, maltreatment, and reporting of such incidents, annually.

• Clinical and administrative supervision creates a culture of compliance and awareness.

The following expectations are communicated to Clients during orientation:

• Clients of similar age are encouraged to socialize and interact with one another while in the program facility, to encourage a sense of community and mutual support.
• Clients should not socialize outside of the program facility while in programming unless such socialization has been discussed with the program staff as a therapeutic intervention and guidelines put in place.
• Adult clients should not socialize with children and adolescent clients outside of their family system under any circumstances. Most children and adolescent programming take place outside of adult programming hours, however adult clients should be mindful that they are not to be in spaces that may be used for children and adolescent activities and therapy sessions outside of adolescent group programming hours.
• Children and Adolescent clients should likewise refrain from socializing with adult clients outside of their family

Gender of person receiving services:

The program serves clients of any gender identity.

How will the program reduce the potential of abuse and/or harm to people related to the gender of people receiving services?

RWC recognizes that the clients served are susceptible to vulnerabilities based on gender in the community such as sexual exploitation and abuse. These matters may be addressed during their therapy sessions. Staff at RWC are trained to respond to these needs. Staff are also required annually to review the PAPP and protocols for reporting abuse. Additionally, staff are trained to look out for boundaries violations including physical, emotional, and relational harm and/or abuse - to ensure clients respect one another.

Describe the range of mental functioning of persons receiving services: Clients served by RWC will be at varying levels of cognitive functioning and may have co-occurring disorders, such as depression, anxiety, behavioral disorders, and other developmental delays. Clients unable to benefit from insight- oriented treatment and have a rudimentary ability to understand verbal and written materials will be referred to a more appropriate service.

How will the program reduce the potential of abuse and/or harm to people related to the mental functioning of people receiving services? RWC Clinical staff use age-appropriate services and are trained and able to work with clients with varying cognitive abilities and mental health diagnoses. RWC Staff practice good consultation and referral practices when the Client needs exceed professional experience.

Clinical and program staff also provide direct supervision of services and model health and safe boundaries, to discourage abuse and mistreatment of clients by other clients and staff.

Describe the range of physical and emotional health of people receiving services: It may be the case that some clients may have physical disabilities such as mobility barriers and may require the use of a wheelchair. Many clients do not adequately maintain their physical health through proper nutrition, exercise, lifestyle choices and care for common illnesses.

Diagnoses of major mental health conditions are common, which can create unstable and poor emotional health. Functional barriers are impacted by, and include low self-esteem, poor socialization, poor impulse control, emotional dysregulation, and disruptive behaviors. Many clients experience factors that increase poor emotional health such as incest, abuse, institutionalization, poverty, and exposure to violence, and chronic instability. Some clients also use street drugs and alcohol outside of the program. Many of these characteristics of their disabilities create dependencies and vulnerabilities. It is common for our clients to encounter re-hospitalizations, trouble with the legal system, victimization in the community, and suicidal ideation with and without intent, and/or history of attempt.

How will the program reduce the potential of abuse and/or harm to people related to the physical and emotional health of people receiving services? The implications of these factors are specified in the Individual Abuse Prevention Plan for each person. RWC Staff may help according to this plan.

RWC staff receive training in the management of disruptive and aggressive behaviors. They also have been trained in alternative communication, first aid, mental health first aid, and making referrals to the appropriate county mental health crisis teams. For individuals with specific vulnerabilities or propensities, the Individual Abuse Prevention Plan specifies plans, if appropriate, to insure the protection of each client and RWC staff.

Describe the range of adaptive/maladaptive behavior(s) of people receiving services: Often, Clients may exhibit behaviors that may be interpreted as being withdrawn, aggressive, irritable, self-injurious, or other such behaviors that may get in the way of their progress. Specific behaviors, characteristics of many individuals with these dual disorders include severe mood swings, hallucinations, and behaviors that may appear out of the ordinary. The program accepts many behaviors if they do not present a threat to injure others or cause property damage.

Describe the need for specialized programs of care for people receiving services: RWC treats the unique needs of clients from BIPOC and low-income communities who are facing housing insecurity, legal involvement, and systemic oppression. Therefore, at RWC some specialization is provided to heal the trauma and mental health that leads to SUD.

Adolescent clients receive special attention to ensure they are receiving services and information in a developmentally and age-appropriate manner.

Describe the need for specific staff training to meet individual service needs: RWC staff may receive additional training focused on multicultural care, trauma-informed care, behavioral disorders, and suicide risks specific to adult, children, and adolescent populations.

How will the program reduce the potential of abuse and/or harm to people related to the adaptive/maladaptive behavior(s) of the people receiving services? If a client poses a substantial risk of harm to themselves or others, they will be referred for additional assessment and likely to a higher level of care. High-risk behaviors will be addressed in the treatment plan, provided the client meets the admission and continuing care criteria and can be served within the scope of an outpatient program. Adolescent clients are supervised during program hours, with RWC staff intervening as needed. RWC staff will also collaborate with other involved contacts to ensure all resources address high-risk behaviors. Clients with predatory histories will be reviewed on a case-by-case basis and may be referred to a program specifically for offenders.

How will the program reduce the potential of abuse and/or harm to people related to the need for specialized programs of care for people receiving services? All RWC staff possess basic education and/or experience in assisting individuals with substance use disorders and mental illness. Additional training and consultation will be provided as needed for new and unique clinical scenarios.

How will the program reduce the potential of abuse and/or harm to people related to the need for specific staff training designed to meet individual service needs? Special training is provided in crisis management, medication, illness management/skills training, recognizing behaviors that indicate escalating problems, and other areas mandated by 245I. The CEO, LICSW, must maintain specialized training related to her specific program responsibilities. Whenever possible, RWC staff participate in specialized workshops and in-service training relevant to their roles. RWC staff must be trained in listening skills, crisis management, interpersonal communication, boundary setting, behavior observation, knowledge of community resources, and the ability to interact with individuals of diverse levels of functioning.

Describe any knowledge of previous abuse that is relevant to minimizing the risk of abuse to people receiving services: If RWC is aware of a vulnerable adult's history of criminal misconduct or physical aggression from a law enforcement authority or through a medical record prepared by another facility, another health care provider, or the facility's ongoing assessments of the vulnerable adult, the identified abuse history is then discussed, based on the client's stated wishes. The Clinical Treatment Team can then determine what additional steps, if any, the program can take to protect the Client from additional harm, and to intervene and address any underlying mental health issues resulting from the abuse. An Individual Abuse Prevention Plan, if deemed appropriate, is then created.

The Clinicians utilize the information provided by the Client to determine the client's counselor assignment, group placement, intensity and ancillary services provided, with the goal of minimizing risk for harm and abuse.

How will the program reduce the potential of abuse and/or harm to people related to the knowledge of previous abuse?

The program uses a trauma-informed approach to providing clinical services, meaning RWC assumes their clients have experienced some trauma during their lifespan. As such, RWC staff is trained on recognizing trauma and treating it from a somatic, holistic, cultural framework, and RWC designs their clinical services and curriculum to minimize any triggers and reduce the likelihood of re-traumatization by ensuring consistent contact with trusted and empathetic caregivers, as well as effective management of the therapeutic milieu. Clients that disclose abuse are offered referrals to mental health staff and/or external providers for individual therapy and trauma-specific therapeutic interventions such as EMDR, prolonged exposure, and TF-CBT.

Assessment of Physical Plant Describe the condition and design of the facility as it relates to the safety of the people receiving services: The program is in a nine-story professional building in the Midway area of St. Paul. The building has an elevator that goes from the lower level (basement) to the ninth floor, and two elevators that go from the lower level (basement) to the eighth floor, all used for various businesses in the professional building. Regular maintenance is performed on the building by an outside agency.

The program offices are on the third floor of the building and occupy three office suites connected by a hallway. The main suite consists of several staff offices, two group rooms, a lobby/waiting area, a bathroom with a passthrough window for urinalysis, a kitchenette, and a conference room. The conference room in that suite will be utilized for treatment team meetings, family conferences, staff training and psychoeducation.

The program has also acquired suite 305 and 307. Both consist of an additional group room and staff offices. RWC Staff will supervise clients as they move back and forth between program spaces.

How will the program reduce the potential of abuse and/or harm to people related to the facility's condition and design in terms of safety for people receiving services? All hallways have Fire Marshall-approved fire extinguishers. Smoke detectors in all rooms are directly connected to an offsite alarm monitoring system. The entire building is protected by a sprinkler system. Formal fire drills are held on each shift monthly. Two exit stairways or outside doors are available on each floor, and exit signs are posted near infrequently used exits. All hallways are lighted day and night and have Fire Marshall-approved fire doors. A building map is posted in the main halls.

Programming for adults, children and adolescent clients will be conducted at different times of day to minimize contact between the different age groups. In the rare circumstance where clients of both groups may have programming at the same time, staff will be trained to ensure they are served in different parts of the program/building, and rules regarding socialization between adults and children and adolescent clients are followed.

Describe any areas of the facility that are difficult to supervise: There are no areas in the primary program facility that are difficult to supervise. The only exception to this would be an unlikely scenario in which an office is left unlocked, or when clients are in transition from one suite to another.

How will the program reduce the potential of abuse and/or harm to people related to the facility's areas that are difficult to supervise? There are offices on all floors accessible to clients to provide increased supervision and RWC staff presence. Individuals are expected to sign in and out of the office when they come and go and are expected to contact RWC staff if they have a change to their schedule.

The front desk staff is a Peer Specialist who is available to help clients navigate the office.

Describe the locations of the facility, including information about the neighborhood and community that the facility is

The program is in the Central-Midway neighborhood of St. Paul, a block from Lexington Avenue and Highway 94. This neighborhood has many businesses and agencies to improve the overall economy of the area. There is an increased police presence in the area due to the continuing concerns about homeless individuals and the potential to purchase drugs and alcohol in the area. There is public transportation on Lexington, Hamline, and University Avenues, within a block of the building. Many clients who come to the program are unfamiliar with the surrounding community and how to keep themselves safe from abuse while in the community. This makes them more susceptible to abuse and crimes while in the community.

How will the program reduce the potential of abuse and/or harm to people related to the location of the facility, including factors about the neighborhood and community? A tour of the facility is given upon a client's first visit. Clients are initially oriented to the building, and if the intake process is being done in the building. Clients are re-oriented as needed.

The program will maintain a good working relationship with the local police and neighborhood. RWC Staff will counsel clients on appropriate community behavior.

RWC Staff cannot control client behavior in the community. If clients engage in behaviors that place them at risk, RWC staff will develop a plan to modify the behavior within the program. This may include discussions with RWC staff, education on safe behavior, contracts between RWC staff and the client, or outside counseling and education. Advocacy is done with and for clients who become victims of crime. Coordination with outside resources occurs to support the client and facilitate any needed intervention.

Clients who demonstrate a lack of familiarity with the community or a low level of independent functioning are given special instructions by RWC staff, such as how to be safe in the community by not going out after dark alone, not carrying large amounts of money on their person, etc.

Describe the type of grounds and terrain that surround the facility: The Central-Midway building is surrounded by a parking lot in the front and back entrances. There is an area where clients can be dropped off/picked up, as well as an appropriate number of handicap parking spaces. The parking lot is surrounded by a fence and is next to a frontage road. There is adequate lighting outside of the building on all sides.

How will the program reduce the potential of abuse and/or harm to people related to the type of grounds and terrain that surround the facility? There are no obstacles that would impede people from entering or leaving the building.

How will the program reduce the potential of abuse and/or harm to people through the type of internal programming provided at the program?

The program will offer the following services to clients: individual counseling, group counseling, wellness education services, continuing care transition planning, co-occurring therapy groups and services, stress management groups, therapeutic recreation, socialization and living skills development, school coordination, peer recovery support, treatment coordination, family programming and counseling, medical consultation and care services, and consultation services. Some individual services may be provided via telemedicine. These services are provided by trained qualified staff in a comfortable and secure setting.

The agency also provides treatment services on-site in the substance use disorder program, but there is a physical boundary between programs and staff are trained on safety and supervision to ensure clients are contained to their programming area.

Describe the program's staffing pattern: RWC provides adequate staffing. The Clinical Director, Treatment Supervisors, Mental Health Practitioners and Clinical- Trainee therapists who either provide services in the office, community or via telehealth.

How will the program reduce the potential of abuse and/or harm to people through the program's staffing pattern? Program staff meets each day in the morning and throughout the day as needed to coordinate care and communicate necessary information.

Program staff have access to professional staff or crisis resources to advise them. There is an on-call consultation system.

Attestation to review and understanding of Program Abuse Prevention Plan

I have received and reviewed Program Abuse Prevention Plan

Clients have the right to be informed before any photograph, audio, or video recording is made of them. This policy ensures that clients are fully aware of and consent to such actions, protecting their privacy and autonomy.

To safeguard clients' rights and privacy by ensuring they are informed and provide consent before any photograph or recording is made.

Photograph: Any still image captured using a camera or other device. Audio Recording: Any sound recording made using an audio recording device. Video Recording: Any moving image recording made using a video camera or other device.

Before taking any photograph or making any audio or video recording, the staff member must inform the client about the purpose, use, and storage of the recording. Provide a clear explanation of why the recording is necessary, how it will be used, and who will have access to it.

Obtain written consent from the client using a standardized consent form that includes details of the recording, its purpose, and how it will be used. The consent form will be sent with the intake packet. In situations where written consent is not feasible, obtain verbal consent and document the client's agreement in their file. Inform the client that they have the right to refuse to be photographed or recorded without any impact on their care or treatment.

Maintain a copy of the signed consent form in the client's file. If verbal consent is given, document the details in the client's file, including the date, time, and context of the consent. Ensure that all recordings are stored securely and are only accessible to authorized personnel.

Use the recordings strictly for the purpose outlined in the consent form. Follow organizational policies on the retention and disposal of recordings, ensuring they are kept only as long as necessary and securely deleted afterward. Inform clients that they can withdraw their consent at any time, and recordings will no longer be made or used from that point forward. Provide clients with access to view or listen to their recordings upon request, within the bounds of confidentiality and legal guidelines.

Attestation to review and understand the Client Rights to be Informed Prior to Photograph or Recording

I have received and reviewed the Client Rights to be Informed Prior to Photograph or Recording

Consent and Release Agreement I hereby give my consent to Roots Wellness Center and its representatives to take photographs and/or make video or audio recordings of me.

I understand that these photographs and/or recordings may be used for the following purposes (check all that apply): Promotional materials

Educational materials Social media Website content

I authorize Roots Wellness Center to use, reproduce, and distribute these photographs and/or recordings in any media, including print and digital formats, for the purposes mentioned above without any further compensation to me.

I understand that my participation is voluntary and that I can withdraw my consent at any time by contacting Roots Wellness Center in writing at info@rwc-mn.com. However, I understand that withdrawal of consent will not apply to materials already produced or disseminated.

I hereby release and discharge Roots Wellness Center and its representatives from all claims and demands arising out of or in connection with the use of these photographs and/or recordings, including but not limited to any claims for defamation, invasion of privacy, or rights of publicity.

 

A. PERMISSION FOR TREATMENT

I agree to permit employees and interns of Roots Wellness Center to provide services to me. I understand that Roots Wellness Center can make no guarantees about the outcome of my treatment, but that I can expect to receive services that are ethical and professional. I understand that Roots Wellness Center agrees to comply with all privacy laws and respects my right to confidentiality. As a client, I agree to attempt to be honest and to disclose information to assist the RWC staff in providing appropriate services.

1. I agree to attend scheduled appointments or notify service providers if I need to reschedule an appointment.
2. I agree to participate in the required treatment planning.

Under the above conditions, I provide my consent to receive services from Roots Wellness Center

1. I authorize Roots Wellness Center to correspond with my insurance company as I have indicated, and with any insurance company with which I will be covered in the future to which I will ask Roots Wellness Center to submit claims. I understand that it is my responsibility to know the benefits and limits of my insurance. I request payment of authorized insurance benefits be made to Roots Wellness Center for any services furnished to me by any provider employed or contracted by this agency. I authorize Roots Wellness Center to release to Minnesota Health Care Programs, its agents, or any insurance company, any information needed to process claims, determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges whether paid by said insurance. I hereby authorize Roots Wellness Center to release all information necessary to secure the payment.

 

3.  If my insurance company sends me payment for services performed by Roots Wellness Center and I have not yet paid my balance in full, I will make payment of at least the amount received from insurance within five working days.

4. This form also authorizes the release of any medical information necessary to process this claim. I understand that I am financially responsible for charges not covered by this authorization.

5. I hereby request and authorize direct payment of benefits specified under my policy or any policy paying benefits to: Roots Wellness Center

Attestation to review and understanding of the Consent Form for Mental Health Services & Financial Agreement

I have received and reviewed the Mental Health Services & Financial Agreement

Roots Wellness Center is committed to providing all our patients with exceptional care. When a service recipient cancels without giving enough notice, they prevent another patient from being seen.

If a client no-show, cancels late, or does not call for their first initial in-person appointment, the second appointment will be virtual to discuss what will work best for the client moving forward. If the client no-shows, cancels late, or does not call for the second meeting, they will be removed from all mental health waitlists. The client will be notified of the removal through follow-up communication.

Ongoing clients, please call your provider on the day prior to your scheduled appointment to notify them of any changes or cancellations. If arriving late to a scheduled appointment, your late arrival will require that the session end at the scheduled time, meaning your session will unfortunately be shorter.

If prior notification is provided, you will have two instances of no call/no show or late cancellation within 24 hours, before we discontinue continue services. In this event, the provider or clinical scheduler will notify you.

Attestation to review and understanding of the Mental Health Cancellation Agreement

Ihave received and reviewed the Mental Health Cancellation Agreement

Roots Wellness Center allows, under certain conditions, the use of Telemedicine technology for outpatient treatment, individual sessions, therapy, and skills sessions at the provider's discretion and with the patient/client consent. Telemedicine is not intended to be a complete replacement for face-to-face sessions and face-to-face sessions are expected to remain the primary mode of service. Acceptable Reasons for the use of telemedical include such things as: Severe weather or transportation barriers making it difficult to travel to your therapist's office, having to remain in home due to ill child, public health crisis, having your ride cancel at the last minute, scheduling conflicts or being out of town. Keep in mind, however, that there might be certain clinical, ethical, or legal factors that would preclude or limit the use of Telemedicine. Your provider will discuss these factors with you on a case-by-case basis.

If you agree to participate in some sessions through telemedicine, please be reassured that all the standard issues related to privacy and confidentiality will still apply. However, please be advised that telemedicine uses the Internet, which is not as secure as the privacy of your provider's office and certain service providers might store copies of videos. It is possible that communication might be intercepted (hacked) or otherwise compromised. Additionally, telemedicine being a relatively new format, the empirical evidence for its efficacy, while promising, is limited.

Also, be aware that if you elect to not use telemedicine for therapy, this will not affect your ability to continue scheduling face-to-face sessions with your provider as available. Please ask your particular provider how telemedicine sessions factors into the no show, and late cancellation policy. I agree to engage in sessions through telemedicine. I am aware of the potential limitations to privacy, confidentiality and service connections associated with telemedicine.

I agree that I will take responsibility to ensure that I am in a place that allows sufficient privacy when engaging in telemedicine, and that I will take every precaution to ensure that my confidential health information is protected on my end of the telemedicine connection.

Attestation to review and understanding of the Telehealth Consent Form

I have received and reviewed the Telehealth Consent Form

Purpose of Treatment:
I, the undersigned, consent to receive mental health and/or substance use disorder (SUD) treatment services from Roots Wellness Center. I understand that treatment may include individual therapy, group therapy, medication management, case management, or other services deemed necessary by my provider.

Confidentiality & Limits:
I understand that my treatment records are protected under the Health Insurance Portability and Accountability Act (HIPAA) and other applicable laws. However, confidentiality may be broken under the following circumstances:

• If I pose a danger to myself or others.
• If there is suspected abuse or neglect of a child, elderly person, or vulnerable adult.
• If ordered by a court of law.
• If disclosure is necessary for medical emergencies or continuity of care with my consent.

Treatment Process & Risks:
I understand that:

• Therapy and treatment outcomes are not guaranteed, and progress depends on various factors.
• I have the right to ask questions and participate in treatment decisions.
• I may experience emotional distress as part of the therapeutic process.
• I can request a change in my treatment plan or provider at any time.

Voluntary Participation & Right to Withdraw:
I understand that participation in treatment is voluntary, and I may discontinue services at any time. However, I am encouraged to discuss my decision with my provider before terminating services.

Billing & Insurance:
I understand that I am responsible for payment of services not covered by my insurance. I agree to provide accurate insurance information and notify the provider of any changes.

Client Acknowledgment & Signature:
I have read and understood this informed consent form. I have had the opportunity to ask questions, and I agree to participate in treatment under these terms.

I attest that I have reviewed and understood the forms in this document, as listed below:

1. Bill of Rights
2. Notice of Privacy Rights & Practices
3. Client Rights and Protections 2451.12
4. Clients Rights, Protection & Grievance Policy
5. Program abuse prevention plans
6. Right to be photographed
7. Consent form to be photographed and audio recorded
8. Demographic Information
9. Mental Health Services & Financial Agreement
10. Mental Health Cancellation Agreement
11. Telehealth Consent Form
12. Intake Forms Acknowledgement

I agree with the information contained in each form to which I have either checked off the box for attestation or signed with my signature.