601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

NOTE: All children or young adults (referred herein as clients) 26 years of age or younger may have additional coverage under their parents, step parents or legal guardian and have to complete the lines of information marked ***. Thank you for your cooperation.

(Please include insurance of self, spouse and of both parents, biological and/or step parents. Include any out of state insurance that applies)

If YES provide the following Step-Parent information:

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

If YES provide the following Step-Parent information:

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

All clients/responsible party are required to disclose if they have received counseling services from another organization/therapist during the current calendar year. Failure to disclose the number of sessions received or to claim no prior sessions received will result in the client/responsible party being billed directly for services provided. The client acknowledges and accepts financial responsibility should their insurance decline payment due to client having used their therapy benefits with another organization/therapist.

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

Thank you for choosing H.O.P.E. Counseling Services (hereby identified as HOPE) to provide for your behavioral health needs. We are dedicated to providing the best possible care and service to you and your family. Your complete understanding of your financial responsibilities is an essential element of your care and treatment. Please understand that payment of your bill is considered a part of your treatment. Full payment is due at the time of service. A payment arrangement must be authorized in advance. This document details our financial policy. Please read carefully and initial acknowledgment, understanding, and acceptance. Our staff is available to answer any questions you might have.

-All patients or guardians are responsible for providing a current copy of all health insurance coverage, at the beginning and throughout the treatment. This includes both primary and secondary insurance and insurance of all parents and legal guardians who provide insurance coverage for the client. This includes coverage by a biological or step-parent in state or out of state. The patient acknowledges understanding that insurance companies reserve the right to deny payment for treatment when the patient fails to disclose all forms of health insurance coverage. Failure to disclose either your Primary or Secondary insurance will result in direct billing to the patient or guardian. The patient or guardian is responsible for notifying the office of any changes in insurance. -For those patients who do not have health insurance coverage, a sliding fee scale application must be completed prior to treatment and a fee will be established. The established fee must be paid prior to each treatment session. For those who appear to be eligible for Nevada Medicaid or Nevada Check-Up our office will assist you with completing the application

-It is the client's responsibility to update all information on file. -The patient or guardian is responsible for notifying the office of any changes regarding current home address and contact information (telephone, e-mail). -If at any point during treatment, you change jobs, become ineligible for insurance, lose behavioral health benefits, insurance carrier changes or additional coverage is added, you must notify us immediately and provide a copy of the new insurance card. Failure to do so will result in direct billing to the patient.

-The patient or guardian is responsible for payment of all services not covered by the insurance company. -We have made prior arrangements with many insurers and plans to accept an assignment of benefits and bill as a courtesy for you. This means that we will bill those plans for which we have an agreement and will only require you to pay the authorized copayment and any additional percentage due at the time of service. This offices policy is to collect payment at the time of service. -If you have insurance coverage with a plan for which we do not have a prior agreement, the charges for your care and treatment are due at the time of the services. -We will bill your insurance for all services provided. Any balances due are your responsibility and is due upon receipt of a statement from our office. -Medicaid is a "Third Party" insurance and is not considered "Primary" for those who have any other insurance coverage. I acknowledge that if I neglect to inform HOPE of any primary insurance, I will be responsible for all the cost associated with treatment.

-The parent and/or legal guardian is responsible for payment of services rendered to the minor child at the time of service.

In accordance with Nevada law, HOPE requires written consent for the release of medical records. Our charge is $.60 per page copied. Medical records request processing time can take up to 30 days.

-Payment, copays, co-insurance, deductibles and no show fees are due at time of service. All cancellations must be made 24 hours in advance prior to appointment. Failure to do so will result in a no show fee of $50.00 per missed session. This fee will need to be paid prior to the next appointment to avoid disruption in treatment. -The agency reserves the right to discharge the patient from services for ongoing no-shows or cancellations. The agency will attempt to contact the patient via telephone, e-mail, or postal mail regarding inconsistent attendance for scheduled appointments.

© H.O.P.E. Counseling Services – Medication Management Intake

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

-All credit card payments are subject to a 4% fee on top of the amount charged.

All payments are final. The client agrees there are no refunds on any payments.

I hereby authorize and direct my insurance carrier(s), including Medicaid, private insurance and any other insurance plan(s), to issue payment directly to HOPE for services rendered to myself and/or my dependents. Regardless of my insurance benefits, I understand that I am responsible for any amount not covered by my insurance.

I hereby authorize HOPE to: (1) release any information necessary to insurance carriers regarding my care; (2) process insurance claims generated in the course of treatmen

I have requested services from HOPE on behalf of myself and/or my dependents, and I understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of my treatment. All accounts 90 days past due will automatically be assigned to a collection agency unless prior arrangements have been made. It is the patient's responsibility to ensure all payments are made on time or that arrangements are made. I also hereby agree to be financially responsible for all charges incurred regardless of the insurance coverage. In the event my account is referred to a collection agency due to lack of payment on my part, I agree to pay all collection/legal fees that may be added to my account. Any balance due must be paid before your next appointment, unless prior arrangements have been authorized. I also agree in order for HOPE to service my account or to collect any balance I may owe, HOPE or its representative may contact me by telephone at any number(s) associated with my account, including wireless telephone numbers, which could result in charges to me. I may also be contacted via text message or e-mail, using any email addresses I have provided. Methods of contact may include pre-recorded/artificial voice messages and/or use of an automated dialing service.

Please take the time to become familiar with your insurance policy. HOPE is not responsible for interpreting your benefit coverage. Any denial or underpayment of services rendered due to your failure to inform us of change in benefits, third party or secondary insurance will be applied to your balance owed to HOPE.

A photocopy of this agreement is to be considered as valid as the original. I also understand and agree that HOPE may amend such terms from time to time.

I have read the financial policy described above. I understand and agree to all provisions of the financial policy.

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

I, _________________________________ give consent to H.O.P.E. Counseling Services, LLC to provide for my or my child's mental health care. I understand that I have the right to confidentiality and that my care is protected under privileged communication and thus my records will not be released to others without my written consent. I also understand that I will actively participate in the development of my treatment plan and that my treatment goals can be updated at any time with my participation. A copy of your treatment plan will be provided to you. I understand I have the right to choose a provider of my choice and if at any time I would like to change providers I have the right to request a plan of care meeting or to speak with a supervisor regarding any concerns. I understand that the services recommended by my counselor have been deemed medically necessary and may or may not be authorized by my insurance carrier. In the event my insurance carrier denies authorization, I understand H.O.P.E. will advocate on my behalf to ensure I receive the most appropriate care to reach my or my child's treatment goals.

H.O.P.E. Counseling is providing our clients with the option to participate in our new communication system. Some of the features include the ability to:

• Receive text message appointment reminders
• Receive phone call appointment reminders
• Submit satisfaction surveys

Please provide us with the following contact information:

I authorize H.O.P.E. Counseling Services to send text messages appointment reminders or voicemail messages to me on my provided or designated cell phone number. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automated dialing service. I understand that I am responsible for confirming my scheduled appointments to avoid any no show or timely cancelation fees. When receiving a text message I understand I will need to reply using one of the options provided on the text message. If I should receive a voice message I understand it is important to select one of the recorded options to confirm or cancel my appointment. This system is being implemented to ensure effective communication and it is part of my treatment plan. All messages will be received from the telephone number 407-902-2960 and that I am encouraged to save this number in my contacts as HOPE Appointment reminder. Standard text message rates may apply. My signature below indicates that I represent and warrant that I am the person legally responsible for all communication for appointment scheduling, that I am at least 18 years of age, and that I agree to all terms and conditions of use for this text/voice messaging services. I understand that this authorization can only be revoked in writing.

Please sign below to indicate that you agree to allow us to use this information in providing your services.

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

H.O.P.E. Counseling Services embraces culturally client centered care. At H.O.P.E. Counseling Services we appreciate your feedback and welcome you to share with us your experience. Client Satisfaction Surveys are available at the front desk. During the course of treatment your therapist or rehabilitation services provider may respectfully challenge your thought process, this is a normal part of treatment. It is expected that you are treated with respect and dignity. If at any time you have a complaint or grievance, please know we are here to listen and take your concerns seriously. It is our hope that together we can resolve any potential issue or problem that may arise. Please ask to speak with or email a member of our Leadership Team with positive or constructive feedback. Your voice matters. Please review your rights as a client at H.O.P.E. Counseling Services:

• To be treated without bias or judgment based on race, ethnicity, color, national origin, religion, gender, sexual orientation, marital status, age, or disability.
• To privacy and confidentiality within the guidelines of HIPAA.
• To actively participate in developing your plan of care and treatment goals.
• To be informed of the professional qualifications/credentials/education upon inquiry.
• For your voice to be heard and your feelings validated.
• To receive prompt consistent services.
• To reschedule and cancel your appointment with a 24 hour notice.
• To be informed of all medically necessary services recommended.
• To receive medically necessary services approved by your healthcare insurance provider.
• To receive affordable services through our sliding fee scale including pro bono services determined by medical necessity and approved by the organization's President.
• To refuse services and to modify your treatment.
• To select a servicing Agency of your choice.
• To request a change in treatment provider.
• To be treated with respect and dignity.
• To receive a copy of your medical record in accordance with HIPAA.
• To refuse to be filmed, audiotaped, or photographed.
• To file a complaint or grievance without retaliation.
• To have a copy of all intake paperwork including this document.

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

As a client or patient receiving behavioral services through telebehavioral health technologies, I acknowledge understanding of the following:

• Telehealth is the use of a telecommunications system to substitute for an in-person encounter for office and out of office visits. A provider has direct visualization of the patient.
• Tele-behavioral health is the delivery of behavioral health services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client/patient who are not in the same physical location.
• The interactive technologies used in telebehavioral health incorporate network and software security protocols to protect the confidentiality of client/patient information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

I, the undersigned, __________________________, or __________________________, my designee(s), on my behalf, agree to participate in technology-based consultation and other healthcare- related information exchanges with HOPE Counseling Services, a behavioral health care practitioner ("practitioner").

• In brief, I understand that my practitioner will not be physically in my presence. Instead, we will see and hear each other electronically.
• I understand that my private health information may be transmitted from my practitioner's mobile device to my own or from my device to that of my practitioner via an "application" (abbreviated as "app").

• I understand that it is my duty to inform my practitioner of electronic interactions regarding my care that I may have with other health care providers.

• During my telebehavioral health consultation, details of my medical history and personal health information may be discussed with myself or other behavioral health care professionals through the use of interactive video, audio or other telecommunications technology.

I {clientname}, have reviewed and understand the HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) and the Notice of Privacy Rights for Substance Use Disorders (SUD) as required by the Standards for Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2).

• I acknowledge the practitioner will be using a HIPAA compliant software, specifically designed for Telehealth use.

• This service is provided by technology (including but not limited to video, video phone and apps) and must involve electronic face to face communication. There are benefits and limitations to this service.
• Regardless of the sophistication of today's technology, some information my practitioner would ordinarily get in in-person consultation may not be available in Teleconsultation. I understand that such missing information could in some situations make it more difficult for my practitioner to understand my problems and to help me get better. My practitioner will be

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673 www.HopeCounselingServices.net

unable to physically touch me or to render any emergency assistance if I experience a crisis. If a crisis should occur the following safety plan may be implemented:

• I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided.

• I understand that I will be informed of the identities of all parties present during the treatment or who have access to my personal health information and of the purpose for such individuals to have such access.

• If a need for direct, in-person services arises, it is my responsibility to contact my practitioner or HOPE Counseling Services office for an in-person appointment or my primary care physician if my behavioral practitioner is unavailable. I understand that an opening may not be immediately available in either office.

• I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services, and benefits.

• These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.
• I understand that telebehavioral health is a new delivery method for professional services, in an area not yet fully validated by research, and may have potential risks, possibly including some that are not yet recognized.
• Among the risks that are presently recognized is the possibility that the technology will fail before or during the consultation, that the transmitted information in any form will be unclear or inadequate for proper use in the consultation(s), and that the information will be intercepted by an unauthorized person or persons.

• The treatment alternatives have been explained to me, including their risks and benefits, as well as the risks and benefits of doing without treatment. I understand that I can still pursue in-person treatment. I understand that the telebehavioral health treatment does not necessarily eliminate my need to see a specialist in person, and I have received no guarantee as to the telebehavioral treatment's effectiveness.

• My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of technologies we have agreed upon today, and modify our plan as needed.

• In emergencies, in the event of disruption of service, or for routine or administrative reasons it may be necessary to communicate by other means:

• I acknowledge, however, that if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person, I am not to seek telebehavioral treatment. Instead, I agree to seek care immediately at the HOPE Counseling Services' office or at the nearest hospital emergency department or by calling 911.

© H.O.P.E. Counseling Services - Medication Management Intake

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673

• My practitioner may utilize alternative means of communication in crisis circumstances.

• I understand that my telebehavioral treatment WILL NOT be recorded and stored electronically as part of my medical records.
• I understand that I am ordinarily guaranteed access to my records and that copies of records of treatment are available to me on my written request.
• I also understand, however, that if my practitioner, in the exercise of professional judgment, concludes that providing my records to me could threaten the safety of a human being, myself or another person, he or she may rightfully decline to provide them. If such a request is made and honored, I understand that I retain sole responsibility for the confidentiality of the records released to me and that I may have to pay a reasonable fee to get a copy.
• Additionally, I understand that my records may be used for Telehealth program evaluation, education, and research and that I will not be personally identified if such a use occurs.
• I hereby authorize these disclosures to take place without prior written consent.

• I understand that at any time, the treatment can be discontinued either by me or by my designee or by my health care practitioners.
• I further understand that I do not have to answer any questions that I feel is inappropriate or whose answer I do not wish persons present to hear; that any refusal to participate in the consultation(s) or use of technology will not affect my continued treatment and that no action will be taken against me.
• I acknowledge, however, that diagnosis depends on information, and treatment depends on diagnosis, so if I withhold information, I assume the risk that a diagnosis might not be made or might be made incorrectly.
• Were that to happen, my Telehealth based treatment might be less successful than it otherwise would be, or it could fail entirely.

• I authorize the release of any information pertaining to me determined by my practitioner, my other health care practitioners or by my insurance carrier to be relevant to the consultation(s) or processing of insurance claims, including but not limited to my name, Social Security number, birth date, diagnosis, treatment plan and other clinical or medical record information.

• I also understand that, under the law, and regardless of what form of communication I use in working with my practitioner, my practitioner may be required to report to the authorities' information suggesting that I have engaged in behaviors that endanger myself or others.

• My health care practitioner has explained how the telebehavioral health treatment is performed and how it will be used for my treatment. My behavioral practitioner has also explained how the treatment will differ from in- person services, including but not limited to emotional reactions that may be generated by the technology.

© H.O.P.E. Counseling Services – Medication Management Intake

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673
www.HopeCounselingServices.net

Counseling Services
H.O.P.E.
Healing, Overcoming,
Preventing, Empowering

• I have received a copy of my practitioner's contact information, including his or her name, telephone number, business address, mailing address, and e-mail address (if applicable).
• I have also been provided with a list of local support services in case of an emergency. I am aware that my practitioner may contact the proper authorities and/or my designated, local contact person in case of an emergency.

• The laws and professional standards that apply to in-person behavioral services also apply to Telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.

• I unconditionally release and discharge HOPE Counseling Services, its affiliates, agents, contractors, employees and my practitioner and his or her designees from any liability in connection with my participation in the remote treatment.

H.O.P.E. Counseling Services - Medication Management Intake

Counseling Services

H.O.P.E.

Healing, Overcoming,

Preventing, Empowering

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673

www.HopeCounselingServices.net

Notice of Privacy Rights for Substance Use Disorders (SUD) as required by the Standards for Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2).

1. All consents must be formally in writing. A verbal consent is not allowed. If authorized by consent, a disclosure is allowed even if it may not be in the individual's best interests.
2. The individual may revoke consent at any time. 42 CFR, Part 2 is silent on the issue of whether the revocation can be oral or must be in writing. HOPE health will honor all oral revocations.
3. The program must always obtain the minor's consent for disclosures and cannot rely on the parent's signature instead; and parental consent for disclosure to a third party is required in addition to the minor's only if the program is required by state law to obtain parental permission before providing treatment to a minor. In other words, if parental consent was not required to treat the minor, then parental consent is not required to make disclosures. If it is required, the consent of both the minor service recipient and the parent or guardian is required to make disclosures.
4. Adolescents (14-18 years old): Typically, parents' consent to treatment for their child to receive mental health services. This is not the case for adolescents receiving substance use disorder treatment. It is recommended that at the onset of mental health services, the adolescent sign releases and consents that are 42 CFR, Part 2 compliant. Otherwise, if the child becomes a participant in co-occurring treatment, the parental consent and releases will no longer be effective.
5. Any disclosure made with written service recipient consent must be accompanied by a written statement that the information is protected by federal law and that the recipient cannot make any further disclosure unless permitted by regulations. Re-disclosure is not allowed unless the individual requests it and signs a valid authorization.
6. Disclosures may be permitted when an individual has a medical condition that poses an immediate threat to the health of an individual or requires immediate medical intervention. In this situation, information may only be disclosed to medical personnel, not family members or "emergency contacts".
7. Under 42 CFR, Part 2, a subpoena, search warrant or arrest warrant, even when it is signed by a judge and labeled a court order, is not sufficient, when standing alone, to require or even permit a program to make a disclosure.
8. HOPE providers have a duty to warn. This can be done without violation by either obtaining a court order, anonymously or a non-patient identifying report (and must not implicate substance use disorder treatment).
9. If there is suspected Child Abuse and Neglect, the program must comply with State mandatory reporting laws in accordance with the procedures included within.
10. In the event of a policy or law conflict regarding confidentiality procedures, HOPE and its employees/contractors will follow the most conservative/restrictive policy.

I (print name)______________________________________, have reviewed and understand the HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) and the Notice of Privacy Rights for Substance Use Disorders (SUD) as required by the Standards for Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2).

© H.O.P.E. Counseling Services – Medication Management Intake

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673

www.HopeCounselingServices.net

Counseling Services
H.O.P.E.
Healing, Overcoming,
Preventing, Empowering

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

In the course of treatment, information regarding your care may be created and/or received by us. Information which can be used to
identify you and which relates to your past, present or future physical or mental condition, receipt of care or payment for care is
considered protected information and is protected by federal and state law.
Federal law imposes certain obligations and duties upon providers of services with respect to your protected information. Specifically, we are
required to:

• Provide you with notice of our legal duties and policies regarding the use and disclosure of your protected information;
• Maintain the confidentiality of your protected information in accordance with state and federal law;
• Honor your requested restrictions regarding the use and disclosure of your protected information, unless under the law we are authorized to release your protected information without your authorization.
• Allow you to inspect and copy your protected information;
• Act on your request to amend protected information, although we are not required to amend the protected information, within sixty (60) days and notify you of any delay which would require us to extend the deadline by the permitted thirty (30) day extension;
• Accommodate reasonable requests to communicate protected information by alternative means or methods; and
• Abide by the terms of this notice.

Generally, your protected information may be used and disclosed by us only with your express written authorization. This written authorization
indudes to whom the information may be disclosed, what information may be disclosed, and for what purpose. You may revoke this
authorization at any time, although any information released prior to the revocation may be used as stated on the consent.
There are some exceptions to this general rule. The following explains how we will use or disclose your protected information without your
authorization:

• Treatment Purposes: We may use or disdose your protected information for treatment purposes to doctors, nurses, hospitals, for instance, in order to facilitate your treatment.
• Payment Purposes: Your protected information may be used or disclosed to your insurance company, for instance, for payment purposes as it may be necessary to disclose this information so that we may properly receive payment for treatment and services provided.
• Health Care Operations: Your protected information may be used or disclosed for health care operations. For example, record review related to quality assurance and improvement activities.
• Compliance and Quality Assurance: We may release your protected information to another individual or entity covered by the HIPAA privacy regulations that has a relationship with you for fraud and abuse detection or compliance purposes, quality assessment and improvement activities, or review, evaluation or training of professionals or students.
• Oversight Activities: Your protected information may be used or disclosed to an oversight agency for activities authorized by law. Examples of oversight activities include audits, investigations, and inspections. In most cases, the oversight activity will be for the purpose of overseeing services and agency compliance with certain laws and regulations.
• Judicial and Administrative Proceedings: If you are involved in a lawsuit or other administrative proceeding, we may release your protected information in response to a court or administrative order. We may also release protected information pursuant to a subpoena or discovery request, but only if efforts have been made by the request or to provide you with notice of the request and you have failed to object or the objection was resolved in favor disclosure, or in the alternative, the requestor has obtained a protective order protecting the requested information.
• Law Enforcement: We may release your protected information to law enforcement officials when required or permitted by federal or state law to do so.
• Emergency Circumstances: Protected information may be disclosed to personnel who have a need for information about a client, such as for the purpose of treating a medical or mental condition which poses an immediate threat to the health and safety of any individual or the public and which requires immediate intervention.
• Individuals Involved in Your Care: We may give out your protected information to a friend or family member who is helping with your care or with payment for your care. However, prior to sharing your protected information in this instance we will first attempt to obtain

H.O.P.E. Counseling Services - Medication Management Intake

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673

www.HopeCounselingServices.net

hereby agree to adhere to the following terms: I will only use one pharmacy to fill/obtain my medication(s). My doctor may talk with the pharmacist about my medication(s) if necessary; I also understand that while I am taking medication, I may be asked to complete a consent for release of information if my provider needs to contact other providers regarding my care and/or use of this medication. I will inform my provider's office of any changes to my pharmacy, prescriptions from other doctors, or if I receive controlled medications from other doctors (for example: a dentist, emergency room provider, etc.). I understand that if this occurs, I must bring this medicine to the office in its original bottle, even if there are no pills/capsules left. I fully understand and agree with the rules outlined above.

HOPE uses e-prescribing methods when prescribing medications, in which an electronic script is sent by your doctor to your chosen pharmacy. This method is meant to improve the quality and efficiency of delivering patient care. Prescriptions are sent to the pharmacy the same day of the medication management appointments.

The use of controlled substances i. e. Xanax, Valium, Klonipin, and other benzodiazepines place a patient at additional risks for addiction. If my treatment plan includes controlled substance the goals of these medications are:

• To improve my ability to work and function at home.
• To help my symptoms of anxiety and panic as much as possible without causing dangerous side effects.

I agree to the following:

• I am responsible for my medications. I will not share, sell, or trade my medicine. I will not take anyone else's medications. FDA Warning: "Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed."
• I will not make any modifications to my prescriptions without the guidance of my doctor.
• I will keep all appointments set up by my providers (such as: primary care, pain management, mental health, physical therapy appointments), and follow my medication treatment plans.
• I agree to give a blood or urine sample, if asked, to test for toxicology screens. Refills will only be made at in person/telemedicine follow up appointments during regular office hours, at the provider's discretion. I must make an appointment to see our providers for any refills of controlled medications. No exceptions will be made.
• I understand that HOPE Mental Health is not a crisis center, and therefore if I experience a crisis situation with my medications I will contact emergency response.

My practitioner will discuss how to effectively use the controlled substance that is being prescribed and I agree to take the medication as directed and to not deviate from the parameters of the prescription as written by my practitioner.

I will discuss my treatment plan with my practitioner, and I have a good understanding of the overall treatment plan and goals of treatment. A main goal of treatment is to use the minimum amount of controlled substances to increase function.

I will review my practitioner's protocols addressing pain management and use of controlled substances.

© H.O.P.E. Counseling Services – Medication Management Intake

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673

www.HopeCounselingServices.net

Counseling Services
H.O.P.E.
Healing, Overcoming,
Preventing, Empowering

It is my responsibility to store and dispose of controlled substances in the appropriate manner. I will store controlled substances in a secure place and out of reach of children and other family members. To safely dispose of unused medications, I may return the medications to a local pharmacy, a local police station, a "drug-take back day" station, or I may safely dispose of them by dissolving them in a "Dettera" bag, which may be available for purchase at a pharmacy.

It is my responsibility to tell my practitioner if I am, or have reason to believe that I am pregnant, or if I am thinking about getting pregnant during the course of my treatment with controlled substances, are there is risk to a fetus of exposure to controlled substances during pregnancy, including the risk of fetal dependency on the controlled substance and neonatal abstinence syndrome (withdrawal).

Due to the risk of possible fatal overdose resulting from the use of controlled substances, the opioid overdose antidote naloxone is available without a prescription at a Nevada pharmacy or in the lobby of HOPE, I understand I can obtain this medication from a pharmacist at any time.

• If I drink alcohol or use street/recreational drugs, I may not be able to think clearly and I could become sleepy and risk personal injury.
• Increased risks of misuse and abuse. Misuse and abuse, also called nonmedical use, can include taking your own medicine differently than prescribed or using someone else's medicine.
• If I or anyone in my family has a history of drug or alcohol problems, there is a higher chance of misuse and abuse.
• All medicines have side effects even when used correctly as prescribed. It is important to know that people respond differently to all medicines depending on their health, the diseases they have, genetic factors, other medicines they are taking, and many other factors. As a result, we cannot determine how likely it is that someone will experience these side effects when taking prescription stimulants. However, it is harmful to take prescription stimulants or other medicines in ways other than exactly as prescribed by your health care professional. Talk to your health care professional if you have questions or concerns about the risks of taking prescription stimulant medicines.

I have read and understand each of the statements written above. I understand that I will have the opportunity to discuss my concerns or get my questions answered regarding controlled substances with my doctor provider.

H.O.P.E. Counseling Services - Medication Management Intake

601 S. Rancho Dr. #A10, Las Vegas, NV 89106 T: (702) 437-4673 F: (702) 438-4673

www.HopeCounselingServices.net

An injection is a way of administering a sterile liquid form of medication into tissues of the body that meet the skin, usually using a sharp, hollow needle or tube. Injections are usually used for drugs which need to act quickly or do not absorb well in the digestive symptom. Some medications can be given as long-acting injections, known as depot injections which is a slow-release medication and is steadily absorbed into the body over several weeks or even months.

In the event that my medical provider suggests an injectable medication as a part of my treatment plan, I understand that the use of an injectable medication is voluntary and that my treatment plan will be left to discretion of myself and my provider. If myself and my medical provider determine that an injectable medication is appropriate for my treatment plan, I understand I will be required to complete an additional injection consent form, and hereby agree to follow all recommendations for appropriate dosage, administration, and maintenance.

We pride ourselves at HOPE in providing the safest environment for our patients. Part of your treatment plan might include routine lab work that will be coordinated through our community lab partners, or we occasionally will accept lab work sent to us by your PCP or specialist.

What is the importance of assessing laboratory values when prescribing medications?

Laboratory monitoring helps ensure safe and effective medication therapy, especially for medications with increased risk of drug-induced toxicity. Indeed, many potential problems are readily detectable and preventable by common laboratory assessment. Standard expectations for routine bloodwork is every 6 months, and for toxicology screens is every 3 months. These timelines are subject to change based on your current medical situation, and will be discussed with you by your provider.

Please join us in taking charge in your own patient safety and best outcome for your recommended treatment here at HOPE.

By signing below, I hereby certify that I understand and agree to comply with HOPE's routine lab work requirements to remain compliant with medication management policies.