Dayton Client Referral Form

Referral Information
The Program requires a complete admission application to assure that the consumer needs and best interests of each applicant are met. The following information is needed to begin the application process. Date ofReferring Source: Referral:
Date of Referral*

MonthDayYear
Date
Referring Source*
If this is a Self-Referral, please select SELF.
Client Name*
DOB*
SS*
Is client their own legal guardian?

Yes
If no please give name of legal guardian
Guardian Name*
Phone#*
City*
Client/Legal Guardian Address
State*
Zip Code*
Primary Insurance No
Secondary Insurance No
Criminal Record

YesNo
If so please attach a brief explanation
Current Symptoms / Behavioral Observations*

AnxietyGets Angry EasilySubstance AbuseSchool / Work ProblemsAttention ProblemsImpulsivitySuicidal ThoughtsRelationship ConcernsHigh Risk ActivitiesMood SwingsTantrums / RagesHopelessnessOther - Depression
Services Requested*

Comprehensive Clinical AssessmentSubstance Abuse ServicesOutpatient TherapyIntensive In HomeCommunity Support TeamTherapeutic Foster CareSupportive EmploymentResidential Level IIIPeer Support Services
Known Medical Problems
Known Diagnosis/Treatment
Notes
Medications
A determination as to the most appropriate services for each consumer will be made based on this information; therefore, it is important to know as much as possible about each applicant. We ask that you provide the above information in its entirety before we start working with the client, SO that we can make an accurate assessment of services needed.

Please forward all information to:

Primary Care Solutions of Ohio 500 Madison Avenue, Suite 200, Toledo, OH 43604
For Office Use Only:
Intake Specialist
LP Name/Number
MEDICAID NUMBER
Orientation Checklist
The following information has been provided as part of the consumer orientation. A check of the item and the signatures of client indicate that all has been explained and is understood by the client.

Mission

Drug Free & Safe Environment

Opportunity for Involvement and Input

Code of ethics/conduct

Abuse or Neglect

Fee for Service

Assessment

Treatment Plan

Infection Control

Regaining Entry Once Discharged

What is Mental Health

Community Based Services

Access to emergency services, after hours

Policy on tobacco products

Policy on illicit or licit drugs brought into the program

Policy on weapons brought into the program

Rights of the clients & Grievance procedures

Services provided, days and hours of operation

Confidentiality policy, limits of confidentiality

Fire, safety, and emergency precautions

Grievance procedure

Discharge/Transition Planning (Stage 1)

Authorization to disclose Information to Primary Care Physicians

Authorization to Use and Disclose Health Information

Client Choice of Services and Providers

Identification of the person responsible for service coordination

Consent for Services/Family Involvement/Follow Up Contact

Discharge/transition criteria and procedures (After Care)
Do you currently have any type of Advance Directives?

YesNo
Client Signature*

Clear
Date*

MonthDayYear
Date
CONFIDENTIALITY POLICY
Name*
DOB*
It is the policy of Primary Care Solutions of Ohio to ensure that all verbal and written information of consumers served is released in a manner that protects the individual's right to confidentiality and adhere to all HIPAA requirements. Information may not be released without the individual's written permission, except as the law permits or requires. Primary Care Solutions of Ohio will make reasonable efforts to limit use, disclosure of, and requests for private health information to the minimum necessary to accomplish the intended
Client Signature*

Clear
Date Signed*

Clear
Guardian Signature

Clear
Date Signed

Clear
Staff Signature

Clear
Date Signed

Clear
Client Guardian Signature*

Clear
Date*

MonthDayYear
Date
GRIEVANCE PROCEDURE
a)Consumers served will be fully informed of the grievance procedures during their orientation to services. In addition, they will receive printed materials that will provide an overview of this process for later reference.

b) Day-to-day issues affecting the consumers served shall be resolved informally between the person served and the primary staff member responsible for his/her service coordination. If the problem or complaint is not resolved to the satisfaction of the person served, the Owners will adhere to the guidelines contained in this policy and assist the person served in accessing the procedures necessary to resolve the concern.

c) If the client does not feel comfortable addressing issues with PCS OH staff persons you may call (888)-380-9990.

d) Consumers served have the right to due process with regard to grievances, and the organization will afford every reasonable opportunity for informal and/or formal resolution of the grievance.

e) Consumers who may bring grievances include, but are not limited to:

1) The person served.

2) The guardian of the person served.

3) The attorney, designated representative, or a representative of a rights protection or advocacy agency of the person served.

a) A grievant shall in no way be subject to disciplinary action or reprisal, including reprisal in the form of denial or termination of services, loss of privileges, or loss of services as a result of filing a grievance.

b) Notices summarizing a person's right to due process in regard to grievances, including the process which grievances may be filed and copies of forms to be used for such purpose, shall be available within each facility and program area.

c) Each person served will be informed of his/her right to grieve and the right to be assisted throughout the grievance process by a representative of his/her choice, in a manner designed to be understandable to the person served.

d) During a formal grievance procedure, the person served will have the right to the following:
4) Assistance by a representative of his/her choice.

5) Review of any information obtained in processing the grievance, except that which would violate the confidentiality of another person served.

6) Presentation of evidence of witnesses pertinent to the grievance.

7) Receipt of complete findings and recommendations, except those that would violate the confidentiality of another person served.

a) In all grievances the burden of proof shall be on the organization, facility, or program to show compliance or remedial action to comply with the policies and procedures established to ensure the rights of consumers served.

b) All findings of a formal grievance procedure shall include: 1) A finding of fact.

2) A determination regarding the adherence of the organization, program, or employee, or the failure to adhere, to specific policies or procedures designed to ensure the rights of consumers served.

3) Any specific remedial steps necessary ensure compliance with organizational policies and procedures.

a) The steps of a formal grievance are as follows:

4) Formal grievances shall be filed first with the supervisor/director of the service unit or program in which the grievance arises.

5) The grievance is required to be in written format. 6) A copy of the grievance shall be forwarded to the administrative head of the organization.

7) The supervisor/director of the service unit or program will meet with the grievant, and/or representatives, immediately following the filing to brainstorm resolution of any related issues that may get in the way of full participation in services. Actions may include, but not be limited to, a change in direct care providers or an adjustment in programming scheduPCS and/or program environments.

8) The organization will issue a formal written response to the grievant, and/or the designated representatives, within five working days, excluding weekends or holidays, of the complaint.

9) The grievance must be signed, dated by client, or individual filing the grievance on behalf of the client.

10) The grievance statement must include;

a) Date
b) Approximate time of incident

c) Description of incident and names of individuals involved.

The steps to appeal a written response to a grievance:

11) If the grievant is unsatisfied with the findings of the written response to a grievance, he or she may appeal the decision to the Owner/CEO within five days, excluding weekends or holidays.

12) The Owner/CEO will issue a formal written response to the grievant, and/or the designated representatives, within five working days, excluding weekends or holidays, of the complaint.

13) If the grievant is unsatisfied with the findings of the written response, he/she will be referred to a third party outside of the organization. Third parties may include organizations such as children's or adult protective services, professional licensing boards, nursing home ombudsmen, or other appropriate organizations that may serve as an advocate for the person served.

a) All staff members of Primary Care Solutions of Ohio will be trained in the implementation of this policy and procedures during orientation, and will receive ongoing training of the procedures to ensure the process is applied in a comprehensive manner is a grievance is filed.

b) Grievances regarding the actions of specific staff members will be handled in accordance with personnel rules and contract provisions. No disciplinary action may be taken, nor facts found with regard to any alleged employee misconduct, except in accordance with applicable personnel rules and labor contract provisions.

c) A Grievance Log will be maintained by the organization detailing the nature of the complaint, relevant information obtained in the investigation, and the outcome of the process. All information contained will maintain the confidentiality of the participants in the process. This record will be reviewed annually by the Consumer Right Committee to determine if there are trends in the complaints, and to identify areas to initiate performance improvement activities. All grievances will be maintained for at least 2 years, records of client grievances will include:

(1) A copy of the grievance.

(2) Documentation reflecting the process used and resolution/remedy of the grievance.

(3) Documentation of extenuating circumstances for extending resolution beyond 21 days.
Client Signature*

Clear
Date*

MonthDayYear
Date
Client Name*
Date*

MonthDayYear
Date
Discussion of discharge should be initiated as early as possible. It is important for you to be a part of this process and to make you aware of the timeframe of services provided.

You will receive an appointment for an assessment. After the assessment and depending on your needs, you may receive one or all of the following services:

Therapy

Case Management

Substance Abuse Treatment

Other:
You will most likely be involved in services at least 3 months but up to 18 months. The time largely depends on your progress toward meeting your goals.

If in the event you decide to not continue services or you transition out of services and are in need of assistance during a crisis please see the information below for additional services OR contact
Physician Name
Phone
Mercy St. Charles Hospital

2600 Navarre Ave, Oregon, OH 43616

Open 24 hours (419) 696-7200

My signature indicates I have participated in this plan and have been offered a copy of it.
Client Signature*

Clear
Date*

MonthDayYear
Date
Authorization to Disclose Information to Primary Care Physician
Communication between those who care for your mental health (Psychiatrist, Psychologist) and those who care for your physical health (Primary Care Physician) is important!

By signing this form you are giving Primary Care Solutions (PCS) permission to share information regarding mental health services and treatment with your primary care physician. This information may include diagnosis, treatment plan, and your progress. We will not release any information without your written permission.
I blanks authorize Primary Care Solutions to release and/or communicate with the Physician listed below regarding my treatment:
Physician Name
Phone
Address
Client Rights: You can end this authorization (permission to use or disclose information) any time by contacting PCS. If you make a request to end this authorization, it will not include information that has already been used or disclosed based on your previous permission.

You cannot be required to sign this form as a condition of treatment, enrollment, or eligibility for benefits.

Information that is disclosed as a result of this Authorization Form may be re-disclosed by the recipient and no longer protected by law.

Patient Authorization: I, the undersigned understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it and that in any event this consent shall expire (1 year) from the date of signature, unless another date is specified. I have read and understand the above information and give my authorization:
I DO give authorization to release mental health information to my primary care physician
I DO NOT give authorization to release mental health information to my primary care physician
(Client Signature) (Signature of Patient's Authorized Rep)

Clear
Date

MonthDayYear
Date
Client Choice of Services and Providers

Primary Care Solutions is committed to ensuring that consumers have the right to choose the application of the service they qualify for, to decide the provider of the services they qualify for, and to select, if they desire, a change in services and/or providers.

By signing this form, you are stating you understand that you, as the consumer, have the right to choose relevant services and which provider delivers those services and that Primary Care Solutions has provided you that choice. Further, you acknowledge that no Primary Care Solutions employees have, in any way, advertently or inadvertently influenced your choice of services or providers. Our services have been explained in simple, non-technical language including risks, benefits and alternatives to proposed treatment. My signature below indicates my consent to treatment for services.

Chosen Provider: Primary Care Solutions of Ohio

I understand that Primary Care Solutions has not influenced my decision in any way.
Client/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Please initial: By placing your initials on this form you are stating you have received a list of local mental health and substance abuse providers*
Date*

MonthDayYear
Date
Name*
DOB*
Consent for Services

I apply for and consent to such medical, psychiatric and / or other service as the staff of Primary Care Solutions may indicate, including diagnostic tests and counseling. I agree to co-operate in the implementation of the services. I have been informed that statistical information concerning my treatment will be submitted to the insurance company for compilation of statistical information statewide.
Family Involvement Consent / Denial
Family Involvement Consent / Denial I consent to have the family members listed below involved in the planning and delivery of the services that I shall be receiving for this period of service. I understand that, without this consent, the agency's employees will not be allowed even to acknowledge to any family member that I am a consumer of their services.
Family members to be involved:
Name
Relationship
Phone
Name
Relationship
Phone
(If parent or legal guardian is indicated under "Relationship" then that individual may sign future forms as the representative of a child consumer)

I do not consent to have family members involved in the planning or delivery of the services I shall be receiving in this period of service.
Follow-up contact consent
I consent to staff of Primary Care Solutions contacting me within 90 days of the termination of this period of service, in order to collect information on the outcomes of that service.
I do not consent to follow-up contact.
I/We agree to give 24-hour notice of cancellation if not participation in planned services and understand that not showing up for planned services, the treatment plan may be reviewed by treatment staff to determine the appropriateness of continued treatment, or discharge.
Signature of clientLegal Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Referral Information

Orientation Checklist

CONFIDENTIALITY POLICY

GRIEVANCE PROCEDURE

Authorization to Disclose Information to Primary Care Physician

Family Involvement Consent / Denial

Follow-up contact consent