Client Intake Packet Logo
  • Intake Form

  • Client Identification Information

    Demographics
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  • I   *   *   understand that in the case of an emergency, the contact listed above may be contacted on my behalf. In theevent that this occurs, office personnel will utilize utmost discretion and ONLY release information pertaining to theemergency at hand.
       *   

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  • Consent to Communication via Unsecure Electronic Devices

    Recovery Glue offers electronic communications to our clients.
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    I, __________________________. (client/legal representative) consent to the following means of communication. I understand that there are limitations to confidentiality using these methods.

  • Authorization to Seek Emergency Medical Treatment

  • In case of the need for emergency medical treatment, we grant the staff of Recovery Glue.org permission to seek treatment.

    We would prefer any such treatment be given by:

  •  I,         hereby certify that all information provided above is accurate at this time. I understand that it is my obligation to report any changes of preferred provider treatment, insurance information,
    allergies, medications, and/or medical diagnosis to staff.
    Pick a Date      

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  • General Client Compliance Expectations

  • Appointment/Time Expectations:

    1. I agree to keep and be on time for all scheduled appointments with the doctor, therapist, case managers (if applicable), as well as any other treatment providers that may be scheduled as part of my treatment plan.

    2. I further agree that any cancellation must be done at least 24 hours in advance by phone call to RecoveryGlue.org

    3. I understand that a 5-minute grace period for 30-minute sessions and a 15-minute grace period for hour-long sessions will be granted to me if communication to my scheduled provider is made. Anything past these time frames with no contact to scheduled providers will be considered a no call no show.

    4. I understand that frequently missed appointments will result in a treatment team meeting to discuss clinical outcomes and client barriers. If deemed appropriate, this may result in a 30 day suspension from services or the discharge from all therapeutic services.

    5. I further understand that two concurrent no call no shows will result in an immediate discharge of all therapeutic services.

    Conduct

    1. I agree to conduct myself in a respectful manner when interacting with staff and other clients who I may come into contact with. I understand that if I conduct myself in an inappropriate manner through behaviors such as, the use of cursing at another individual, raising my voice by means of intimidation, not being visable on camera during Telehealth sessions, aloofness, disengaged, distracted or digressive behavior, enlisting fear through threats, and/or acts of physical violence will not be tolerated. I understand that RecoveryGlue.org has a zero-tolerance policy for abusive or aggressive behavior towards staff or other clients. Any such behavior may result in immediate discharge and a “no re-admit” status.

    2. I agree that I will NOT present for any session intoxicated or under the influence of any substance not prescribed to me. If I am determined by providers to be under the influence of substances, providers reserve the right to refuse to see me.

    3. As a client it is my responsibility to keep staff up to date with all current information including, but not limited to; change in addresses, phone numbers, insurance information, payment methods. If failing to do so results in client complications in treatment, appointments, or payment, Recovery Glue will not be responsible for any damages that may come as a result (i.e. unpaid bill, canceled appointment without client notification, etc.

    Technology

    Upon entry into our program, you will be assigned a staff member and participate in aorientation training to help ensure you can successfully navigate our Best Notes online therapy portal. This portal is what connects you to ALL your Telehealth sessions and most RecoveryGlue.org services. 

    We require that you to be proactive and inform your assigned staff member directly  should any of the following occur:

    * If you cannot operate BEST NOTES portal independently at any time, for any reason.

    * If your email or phone number changes or becomes unaccessible to you.

    Failure to be proactive to remedy technology issues may result in removal from the program.

    Communication and Responsiveness

    It is the clients sole responsibility to provide RecoveryGlue.org staff their correct and valid email addresses and working phone numbers.

    We require swift responsiveness when contacted by a RecoveryGlue.org staff member. A maximum of 18 hrs is allowed to return emails, texts, or phone calls.

    Failure to respond to within 18hrs will result in a 30 day probation of services. After the probation period has expired, any further occurrence will result in permanent removal from the RecoveryGlue.org program.

     

     

  • HIPAA Privacy of Information Policies

  • The following information describes the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information.

    Our Legal Duties

    State and federal laws require that we keep your medical records private. Such laws require that we provide you with this notice informing you of our privacy of information policies, your rights, and our duties. We are required to abide by these policies until replaced or revised. We have the right to revise our privacy policies for all medical records, including records kept before policy changes were made. Any changes in this notice will be made available upon request before changes take place.

    The contents of material disclosed to us in an evaluation, intake, or counseling session are covered by the law as private information. We respect the privacy of the information you provide us, and we abide by ethical and legal requirements of confidentiality and privacy of records.

    Use of Information

    Information about you may be used by the personnel associated with this clinic for diagnosis, treatment planning, treatment, and continuity of care. We may disclose it to health care professionals who provide you with treatment, such as doctors, nurses, mental health professionals, mental health students, and mental health professionals or business associates affiliated with this clinic, such as billing, quality enhancement, training, audits, and accreditation.

    Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian or personal representative. It is the policy of this clinic not to release information about a client without a signed release of information except in certain emergency situations or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.

    Duty to Warn and Protect

    When a client discloses intentions or a plan to harm another person or persons, the healthcare professional is required to warn the intended victim and report this information to legal authorities. In cases where the client discloses or implies a plan for suicide, the healthcare professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

    Public Safety

    Health records may be released for the public interest and safety, for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.

    Abuse

    If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child or vulnerable adult is in danger of abuse, the healthcare professionals are required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim and his or her safety appears to be at risk, we may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator.

    Prenatal Exposure to Controlled Substances

    Healthcare professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

    In the Event of a Client’s Death

    In the event of a client’s death, the spouse or parents of a deceased client have a right to access the records of their spouse or child.

    Professional Misconduct

    Professional misconduct by a healthcare professional must be reported by other healthcare professionals. In cases when a professional or legal disciplinary meeting is being held regarding the healthcare professional’s actions, related records may be released in order to substantiate disciplinary concerns.

    Judicial or Administrative Proceedings

    Healthcare professionals are required to release records of clients when a court order has been placed.

    Minors/Guardianship

    Parents or legal guardians of a non-emancipated minor client have the right to access the client’s records.

    Other Provisions

    When payment for services is the responsibility of the client, or a person who has agreed to provide payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid, it may be reported to credit agencies, and the client’s credit report may state the amount owed, the time frame, and the name of the clinic or collection source.

    Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information that may be requested includes types of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries.

    Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases, the name of the client or other identifying information is not disclosed. Clinical information about the client is discussed. Some progress notes and reports are dictated/typed within the clinic or by outside sources specializing in (and held accountable for) such procedures.

    In the event the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please notify us in writing where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we do not say the name of the clinic or the nature of the call but rather the mental health professional’s first name only. If this information is not provided we will adhere to the following procedure when making phone calls: First we will ask to speak to the client (or guardian) without identifying the name of the clinic.

    If the person answering the phone asks for more identifying information, we will say that it is a personal call. We will not identify the client in an effort to protect the client's confidentiality. If we reach an answering machine or voicemail, we will follow the same guidelines.

  • HIPAA Privacy of Information Policies, con't

  • Your Rights

    You have the right to request to review or receive your medical files. The procedures for obtaining a copy of your medical information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. If your request is denied, you will receive a written explanation of the denial. Records for non-emancipated minors must be requested by their custodial parents or legal guardians. The charge for this service is $.10 per page, plus postage.

    You have the right to cancel a release of information by providing us with a written notice. If you desire to have your information sent to a location different from our address on file, you must provide this information in writing.

    You have the right to restrict what information might be disclosed to others. However, if we do not agree with these restrictions, we are not bound to abide by them.

    You have the right to disagree with the medical records in our files. You may request that this information be changed. Although we might refuse to change the record, you have the right to make a statement of disagreement, which will be placed in your file.

    You have the right to know what information in your record has been provided to whom. Request this information in writing.

    Complaints

    If you have any complaints or questions regarding these procedures, please contact the Alteri clinic. We will get back to you in a timely manner. You may also submit a complaint to the U.S. Department of Health and Human Services and/or the Kentucky State Board of Examiners of Psychology. If you file a complaint, we will not retaliate in any way.

    You will be provided with a written copy of this Privacy of Information Practices upon admission to Recovery Glue services.

    I acknowledge that I have read and understood the information regarding the confidentiality of my medical records, my rights, and the procedures outlined above. By signing below, I acknowledge that I am aware of my rights and responsibilities in relation to my medical information.

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  • Crisis Intervention Services

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    Suicidal? Need help now? Call 911 or call one of the helplines below

     

    National Suicide Prevention Lifeline:

    Call: 900-273-8255

    Text: 988

    Visit www.suicidepreventionlifeline.org to chat online

     

    Veterans Crisis Line:

    Call: 800-273-8255, press 1

    Visit www.veteranscrisisline.net to chat online

     

    Self-Injury Foundation’s 24-hour talk line:

    Call: 800-334-HELP (4357)

     

    Eating Disorder Hotline:

    Call: 844-228-2962

     

    Addiction Hotline:

    Call: 877-226-3111

     

    Sexual Assault Hotline:

    Call: 800-656-4673

     

    Domestic Violence Hotline:

    Call: 900-799-7233         Text: “START” to 88788

    Visit www.thehotline.org to chat online

     

    LGBTQIA+ Specific Crisis Lines:

    Trevor Project:

    Call: 866-488-7386          Text: “START” to 678678

    Visit www.thetrevorproject.org to chat online

     

    GLBT National Help Center General talk line:

    Call: 888-843-4564

     

    GLBT National Help Center Youth talk line:

    Call: 800-246-PRIDE (7743)

     

    Trans Lifeline:

    Call: (877) 565-8860

    Visit www.translifeline.org to chat online

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    If you have a mental health emergency at any time, call 911. Otherwise, if you have a crisis or want to speak to a mental health professional, you may reach a staff member during regular workdays (Monday through Friday).

    RecoveryGlue.org Services

    Please understand that while your service providers cannot provide crisis intervention services 24/7, they can be contacted anytime during business hours M-F 9am-5pm (unless otherwise notified). Please speak to your provider, case manager, or additional office staff if you need the contact information for your provider(s). (Please note that crisis intervention services even during business hours are subject to provider availability and cannot be conducted via text due to HIPPA).

     

    _____________________________________________

    I have read and understand the  RecoveryGlue.org Crisis Intervention services. I

    acknowledge I have been given a copy of crisis intervention numbers.

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