CLIENT INTAKE FORM

FACE SHEET

Clients have the right to:

• Receive quality services in a respectful manner without discrimination;
• Make an informed choice of services;
• Know the qualifications of staff who provide them with services;
• Receive and understand information and instructions about their service needs;
• Consent to or refuse services before they are provided;
• Know the nature and purpose of services;
• Be informed prior to any transfer or discharge from services;
• Expect confidentiality of information and protection of their child’s or their records;
• Receive timely response to their needs along with reasonable continuity and coordination of services;
• Know about charges for services;
• Expect the right to privacy;
• Freedom from abuse, financial or other exploitation, retaliation, humiliation and neglect;
• Clients have access to information pertinent to the person served in sufficient time to facilitate his or her decision making;
• Access to referral to: legal entities for appropriate representation, self-help support services and advocacy support services;
• Be part of the process of updating the service plan when his or her needs change; and
• Receive all services at Takes A Village For Change or be referred to another agency.
• Know how to voice any grievance about their services;
• Receive services based on an individual service plan;
  Be part of the process of updating the service plan when his or her needs change.

Clients have the responsibility to:

• Give accurate information about their mental health, substance use, and domestic violence issues as well as other circumstances which might impact upon the care of their children;
• Assist by making and keeping a safe environment (including respecting clinician’s wishes regarding the use of substances and tobacco products during sessions and exposure to weapons during sessions in the home);
• Notify the agency if scheduled appointments need to be changed;
• Notify the agency if there is a change in your living arrangements;
• Work with staff in planning, reviewing and changing their individual service plans.

Clients can expect that TAVFC clinicians and coordinators will:

• Provide a safe and supportive environment for clients to express themselves and express their needs;
• Be culturally competent, professional and will follow the codes of conduct outlined by the agency;
• Maintain appointments and notify clients in a timely manner if appointments need to be canceled;
• Collaborate with clients regarding individual service plans (Counselors and coordinators will collaborate with clients and/or family to develop treatment goals, interventions, and timelines for goal achievement and
  progress).

• I understand that as the legal guardian of the above-mentioned client I am responsible for providing Takes A Village For Change legal documentation in the form of court order or custody agreement.
• I hereby consent to Takes A Village For Change to provide onsite, offsite, tele-health health services.
• I understand that I am being treated for mental health services and will be scheduled for individual psychotherapy sessions, group psychotherapy sessions, medication management sessions, evaluations, case coordination sessions, community based PRP services and assessments on an as needed basis.
• I understand that all information concerning participation of myself is confidential and that no information will be given without prior written consent from me.
• I agree that I have been fully oriented to the program’s services and the treatment that is being provided to me.
• I have reviewed my rights and responsibilities as a client, and I am aware of the grievance process and the discharge/termination policy of this agency as outlined in the Maryland Notice form.
• In agreeing to receive services at Takes A Village For Change, I understand that I shall assist in developing and following the individualized treatment plan that will be implemented by Takes A Village For Change and shall ensure that all the scheduled appointments are kept.
• I agree to allow Takes A Village For Change to attain authorization for services and bill my insurance accordingly for the reimbursement for initial evaluations, individual, family or group therapies until services are terminated. I understand that there are no fees for services.
• I understand that appropriate referrals, transfers or continuation of services referrals will be made upon anticipation of the termination or interruption of services.
• I understand that my information will not be used for research purposes without my prior consent and/or without direct or implied deprivation or penalty for refusal to participate.

 

RISKS AND BENEFITS OF MENTAL HEALTH TREATMENT

Receiving mental health services can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and/or helplessness. On the other hand, receiving mental health services has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific challenges and significant reduction in feelings of distress. However, there are no guarantees of what will be experienced while participating in mental health treatment. In either situation you will have the support of your therapist throughout the process.

CONFIDENTIALITY

All information given to or obtained by Takes A Village For Change will be used only for treatment and administration of the program. Information may be released for the purpose of treatment or rehabilitation services or if required by Federal Law or in response to legal investigations and court order. Information requested about my records for any other purpose can only be released by my written consent.

Prior to consenting to treatment, Takes A Village For Change (TAVFC) will discuss the estimated cost of payment and payment options with the client. TAVFC billing policy states that if a client does not have insurance coverage, the client may be billed by Takes A Village For Change.

For clients with insurance, services will be billed by Takes A Village For Change through the client’s insurance company. It is the client’s responsibility to know their insurance benefits and whether the services they are to receive are a covered benefit. The client will be responsible for any co-pay or balance due that Takes A Village For Change is unable to collect from the insurance carrier for whatever reason. If there is a copay, copays are collected at the time of service.

Cancellations and Missed Appointments

When an appointment is scheduled, that time is reserved specifically for you. If the appointment is missed or canceled without enough notice, the therapist is unable to make use of that time.

Therefore, sessions must be canceled 24 hours in advance. If a client does not give 24 hours’ notice it is considered a “no show”. Clients who do not give 24 hours' notice of cancellation and are considered No Show are charged for a $50 fee.

To avoid a $50 cancellation fee clients are to attend all scheduled obligations or if necessary to cancel it must be done no less than 24 hours’ time of a scheduled appointment. If a client does not show two times consecutively the client will have to wait 30 days before being able to schedule a follow up appointment, unless the client is experiencing a mental health crisis.

Please read and then sign to indicate your full understanding of your participation in this program.

• You are expected to be on time or call if you are going to be late. This means that you may be required to rearrange other obligations while participating in this treatment program.
• You are expected to abstain from the use of alcohol and all other mood-altering substances/chemicals during your participation in the program. Any medications you are taking prescribed or over the counter must be reported.
• You are expected to come to group and individual sessions and fully participate in group discussions.
• Should you arrive late without notifying your counselor in advance, the group facilitator is NOT required to grant admittance into the session thus resulting in an unexcused absence and no credit for the day.
• You are required to stay the entire duration of the group or individual session.
• You may not leave the group prematurely for no reason unless previously discussed with your individual counselor. You are required to dress appropriately in accordance with the Takes A Village For Change dress code policy.
• You agree to complete all treatment plan goals during your time in IOP/OP
• You agree to preserve the anonymity and confidentiality of all group members.
• You must not divulge the identity of any group member or the context of any group sessions to persons outside of the group including your spouse/mate. WHAT GOES ON IN GROUP, STAYS IN GROUP, NO EXCEPTIONS!
• You agree to remain in the program until program completion. Takes A Village For Change program consists of Intensive (IOP) and Standard (OP) Outpatient Treatment.
• If for any reason you desire to leave the program prematurely, you will raise the issue for discussion with your individual counselor during a scheduled individual session.
• You are not at liberty to discuss any discrepancies with Takes A Village For Change during group discussions. You are encouraged to refrain from becoming involved romantically, sexually, or financially with other group members during your tenure in the group.
• Group members are not allowed to and are STRICTLY PROHIBITED from providing any professional (medical, legal, etc.) or business services to one another.
• You acknowledge that you will be immediately terminated from the treatment program if you offer alcohol/drugs to any other group member or use any substances with any other group member while at Takes A Village For Change.
• You agree to give a urine sample for drug testing whenever requested by the group leader or your individual counselor.
• You are at liberty to discuss IN PRIVATE if any group members are experiencing suicidal or homicidal ideations or are threatening to harm any group member or instructor.
• You will not make threatening comments or statements to group facilitators, group participants or individual counselors.
• You will not use your cell phone during group sessions. During breaks you are provided with an opportunity to make phone calls.
• You understand that any violation of rules and regulations will result in being placed on a BEHAVIORAL CONTRACT with the recommendations of termination of services.

Summary

• Services offered by Takes A Village For Change (TAVFC) Psychiatric Rehabilitation Program (PRP) are designed to facilitate an individual’s recovery and independence, including their ability to make life’s decisions and pursue opportunities for their personal betterment. To encourage a client’s full community participation, Takes A Village For Change PRP promotes the use of community resources and self-help organizations.
• Services may also be rendered at the program’s site off-site throughout the community. 

Clients must receive Maryland Medicaid to be eligible for services which are classified into three major areas:

Eligibility & Screening Services:

• Assistance with verifying Medicaid status and medical application if needed
• Assistance with applying for entitlements for which a client may be eligible

Evaluation & Planning Services:

• Review of somatic status
• Conducting rehabilitation assessments
• Individualized rehabilitation plans

Rehabilitation & Support Services:

• Referral to services the PRP does not provide such as somatic care, speech and language services, occupational therapy, special education, vision and hearing services, self-help organizations, and substance abuse services.
• Rehabilitation and recovery activities: improvement / restoration of self-care skills, social skills, independent living skills, cultural interests.
• Medication services to include administration and monitoring by licensed or certified professionals.
• Health promotion and training activities fostering proper nutrition and exercise.
• Promotion of individual wellness self-management and recovery.
• Care coordination services i.e. assistance applying for and maintaining case management for entitlement program benefits such as Public Assistance to Adults (PAA), Temporary Disability for Adults (TDAP), Temporary Cash Assistance (TCA), Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medical Assistance (MA), Disability bus pass assistance, etc.
• Linkage to mental health services in more restrictive settings.
• Coordination of Medical transportation to medical appointments.
• On-call emergency response

READ CAREFULLY - THIS AFFECTS YOUR LEGAL RIGHTS

In exchange for participation in the activity of mental health treatment organized by Takes A Village For Change, 413 Eastern Blvd., Essex, M.D. 21221, and/or use of the property, facilities and services of Takes A Village For Change, you must sign and agree for myself and (if applicable) for the members of my family, to the following:

AGREEMENT TO FOLLOW DIRECTIONS

I agree to observe and obey all posted rules and warnings and further agree to follow any oral instructions or directions given by Takes A Village For Change, or the employees, representatives or agents of Takes A Village For Change.

ASSUMPTION OF THE RISKS AND RELEASE

I recognize that there are certain inherent risks associated with the above described activity and I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge Takes A Village For Change for injury, loss or damage arising out of my or my family's use of or presence upon the facilities of Takes A Village For Change, whether caused by the fault of myself, my family, Takes A Village For Change, or other third parties.

INDEMNIFICATION

I agree to indemnify and defend Takes A Village For Change against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family's use of or presence upon the facilities of Takes A Village For Change.

FEES

I agree to pay for all damages to the facilities of Takes A Village For Change caused by any negligent, reckless, or willful actions by me or my family.

APPLICABLE LAW

Any legal or equitable claim that may arise from participation in the above shall be resolved under Maryland law.

NO DURESS

I agree and acknowledge that I am under no pressure or duress to sign this Agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this Agreement if I so desire. I further agree and acknowledge that Takes A Village For Change has offered to refund any fees I have paid to use its facilities if I choose not to sign this Agreement.

ARM'S LENGTH AGREEMENT

This Agreement and each of its terms are the product of an arm's length negotiation between the Parties. In the event any ambiguity is found to exist in the interpretation of this Agreement, or any of its provisions, the Parties, and each of them, explicitly reject the application of any legal or equitable rule of interpretation which would lead to a construction either "for" or "against" a particular party based upon their status as the drafter of a specific term, language, or provision giving rise to such ambiguity.

ENFORCEABILITY

The invalidity or unenforceability of any provision of this Agreement, whether standing alone or as applied to a particular occurrence or circumstance, shall not affect the validity or enforceability of any other provision of this Agreement or of any other applications of such provision, as the case may be, and such invalid or unenforceable provision shall be deemed not to be a part of this Agreement.

DISPUTE RESOLUTION

The parties will attempt to resolve any dispute arising out of or relating to this Agreement through friendly negotiations amongst the parties. If the matter is not resolved by negotiation, the parties will resolve the dispute using the below Alternative Dispute Resolution (ADR) procedure. Any controversies or disputes arising out of or relating to this Agreement will be submitted to mediation in accordance with any statutory rules of mediation. If mediation is not successful in resolving the entire dispute or is unavailable, any outstanding issues will be submitted to final and binding arbitration under the rules of the American Arbitration Association. The arbitrator's award will be final, and judgment may be entered upon it by any court having proper jurisdiction.

Summary

Services offered to you by Takes A Village For Change, Outpatient Mental Health Center (OMHC), are categorized into three major components: evaluation, treatment and supportive services. To be eligible to receive services, clients must receive Medicaid and/or Medicare. All clients will receive an initial evaluation from a licensed clinician to gather information about the client's personal history and assess the client’s treatment needs. At the time of intake, the treatment provider will discuss the therapeutic process with clients, including potential reactions to treatment; informed consent and confidentiality; and the client’s rights and responsibilities. Clients have the right to discuss, with their provider, the options to the proposed treatment.

Takes A Village For Change (TAVFC) strives to provide clients with the best care possible. However, with any type of therapeutic services, there is a potential risk of discomfort. During the client's treatment, the provider will explain any risks or harm.  TAVFC encourages clients to talk to their treatment provider if they are uncomfortable with the services being provided and to process their feelings with their provider.

Clients have a right to withdrawal or decline treatment at any time. However, withdrawing from the treatment may cause clients to regress and/or need additional support services.

Clients have the right to speak to their treatment provider and/or the Director of Programs regarding any grievances about their treatment or treatment provider.

Clients will receive these services on an as-scheduled/as-needed basis. Evaluative services are rendered by licensed mental health professionals who are credentialed at the highest level of licensure in their field and include but are not limited to:

• Assessment and diagnosis of mental health illness based on medical necessity for the treatment of the condition.
• Co-occuring substance abuse screening assessments and treatment for referral and/or treatment of the condition are based on medical necessity.

Comprehensive reviews of Somatic Status Treatment services provided which include:

• Mental Health treatment - Individual therapy, family therapy, and group therapy.
  Psychological evaluation and testing
• Co-occurring substance abuse treatment
• Medication services - prescription, administration, monitoring, and medication education.
• On-call and crisis intervention services (see Crisis Intervention Services Section)

Support services which include:

• Referral to services OMHC program does not provide such as psychiatric rehabilitation program services, primary care physician services, self-help organizations and inpatient substance abuse treatment services
• Education regarding medication
• Case coordination services i.e. assistance applying for and maintaining case management for entitlement program benefits such as Public Assistance to Adults (PAA), Temporary Disability Insurance (SSDI), Supplemental Security Income (SSI), Medical Assistance (MA), disability bus pass assistance, etc.
• Linkage to mental health services in more restrictive settings
• Coordination of Medicaid transportation to medical / mental health treatment appointments.

We anticipate a smooth working relationship with you. However, occasional misunderstandings may arise. If they do, we strongly encourage you to contact the Director or Programs at (410) 689 5057 so that we can address your concerns. If you are not satisfied with our response, you have the right to launch the complaint process by filing the attached complaint form directly to the Complaint Unit.

Takes A Village For Change (TAVFC) amended complaint policy and procedure does not establish any barriers for you to file a complaint. TAVFC does not retaliate in any way for reported grievances or complaints. It is our desire to work through any differences that may arise and move forward in our relationship with our clients.

Information regarding the complaint policy and procedure is in the handbook given to all clients during their orientation/intake. The handbook is reviewed and updated annually to include any new information regarding the complaint process.

Complaint Policy Overview

• It is the policy of TAVFC to comply with, and to require TAVFC employees to comply with, the TAVFC supports the principle that all customer complaints should be viewed and taken positively.
• TAVFC ensures that all complaints will be treated seriously and dealt with properly with an emphasis on the honest and thorough process of consideration, with the prime aim of satisfying the concerns of the complainant.
• All written complaints that are received will be registered within 2 days and a response provided within 10 days. If additional time for investigation and response are required, the interim report expressing what findings were made and request for an additional time for investigation should be provided to the complainant. Please note: You will be notified that your complaint has been received.
• TAVFC has an established mechanism for responding to and keeping a record of those complaints and findings of investigation.
• In cases that involve allegations of fraud or time-sensitive issues TAVFC is obliged to provide expedited review of such complaints.
• An allegation of any employee, supervised provider, or board member suspected of child abuse or neglect will be given immediate consideration.
• TAVFC guarantees that all records, information, organizational reports and summaries regarding received complaints will be available for the accrediting entity or other governmental authorities upon their request.
• TAVFC pursues a no discouragement/no retaliation policy meaning that TAVFC employees and board members are prohibited from discouraging clients from filing complaint and may not retaliate against a client or prospective client who filed such a complaint.
• Anonymous complaints cannot be given consideration
• TAVFC believes that complaints can be a way to learn where and how the service can be improved. Therefore, TAVFC develops and implements TAVFC own services quality improvement program based on qualitative and quantitative analysis of TAVFC actions and performances
  Present complaint policy provisions are open to the public and available in electronic and hard copy versions. It is necessary for all TAVFC clients to be familiar with these provisions before signing the contract with the agency.

How to File a Complaint or Grievance

1. Request the complaint grievance form from any TAVFC staff person.
2. Complete the complaint grievance form. You may request assistance from any TAVFC staff person.
3. Submit the complaint form to the complaint box.
4. We will respond to your complaint within 2 business days.

If you are not satisfied with your initial solution to your complaint, you may appeal to the Program Director, then to the Advisory Board, then to the Chief Executive Officer by requesting their information from any of the TAVFC staff people you work with.

By signing you certify the following:

• That I have participated in orientation to Takes A Village For Change on or before the date I begin to receive services;
• That I received information both verbally and in writing on the description of services available to me;
• That I received information both verbally and in writing on my rights and responsibilities;
• That I received information both verbally and in writing regarding the programs hours and on-call procedures;
• That I received information both verbally and in writing regarding the programs procedures for discharge;
• That I received information both verbally and in writing regarding the programs procedures for confidentiality and HIPPA practices;
• That I received information both verbally and in writing regarding crisis intervention services;
• That I received information both verbally and in writing on the complaint and grievance process; and
• That I received information both verbally and in writing with regard to my advance directive for mental health services;
• That I received information both verbally and in writing on my informed consent to treatment;
• That I received information both verbally and in writing with regard to the finance policy, waiver of liability, medical records release;
• That I received information both verbally and in writing on the entitlement programs for which I may be eligible.