• GENERAL INFORMATION

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status*
  • I am willing to provide information for an emergency contact*
  • Format: (000) 000-0000.
  • Is the above named person aware that you are in treatment?*
  • Do you have any allergies?*

  • PATIENT RESPONSIBILITIES

    1. Notify counselor when you will be unable to keep counseling sessions.
    2. Dose as scheduled.
    3. Submit proper urine specimens when required to do so.
    4. Refrain from illicit drug use.
    5. Keep all physician and counselor and group appointments.
    6. Follow up on all referrals for further evaluation/treatment.
    7. Submit chest x-ray or blood work results to nursing staff as requested.
    8. Bring in prescriptions to be documented in your chart by nurse as received or refilled.
    9. Conduct self appropriately and refrain from threatening or intimidating behaviors.
    10. Participate in the development of treatment plans.
    11. Return take home bottles as required on the next dosing day.
    12. Responsibly store take home medication in approved lock box.
    13. Fulfill all financial obligations to the facility including income verification.
    14. No loitering in and around the facility or within a two-block area.
    15. Do not get involved in illegal activity including theft of property: or the illegal possession or purchase of drugs.
    16. Do not bring a weapon of any kind to the clinic.
    17. Have evidence on drug tests that prescribed medications are taken as directed.
    18. Obtain methadone and other controlled drugs from a single source only.
    19. Comply with all take home rules.
    20. Respond to all call backs when contacted.
    21. Notify the clinic, if possible, when you will be unable to come to the clinic for five (5) consecutive days.
  • I have read and understand my responsibilities and agree to fulfill them while enrolled in the agency.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Infractions that May Lead to Discharge

  • Below is a list of infractions that may lead to discharge. Please review this list and if further explanation is needed, contact your primary therapist or the Program Director.
    1. Continued illicit drug use including alcohol.
    2. Diverting methadone and/or urine used for drug screens.
    3. Dosing at more than one (1) facility.
    4. Failure to comply with the Take-home Bottle Policy and Procedure.
    5. Loitering. Including any businesses within a six-block area from Star Center.
    6. Continual failure to keep counseling appointments.
    7. Sporadic dosing or excessive absences of dosing.
    8. Inflicting or threatening to inflict physical injury to any staff member and or clients.
    9. Curse, degrade or intimidate any staff member and/or client.
    10. Sexually harassing any staff member and/or client.
    11. Theft (or attempted theft) of property from the premises of Star Center.
    12. Possession of any illegal (or otherwise) weapons on the premises of Star Center.
    13. Unauthorized possession and/or use of any intoxicants, narcotics or other controlled substances on the premises of Star Center.
    14. Deliberate destruction or abuse of property of Star Center.
    15. Committing ethical, illegal and/or immoral acts on the premises of Star Center.
    16. Failure to fulfill financial obligations including insurance verification.
    17. Filming, photographing, or otherwise recording patients, staff, or Star Center premises.
  • I have read the above list of infractions which can lead to discharge, and fully understand each of the above rules and the consequences there of.
  • STAR Center, Inc.

  • DOSE AND GO POLICY

  • To reduce any incident of any illegal or unacceptable behavior, we have implemented a "Dose and Go" policy. All patients are required to complete any necessary appointments before being dosed. This may include: submitting a urine drug screen, having blood work completed, a physician review and or individual or group counseling session. After this requirement is completed, the patient may receive their medication and or take-home medication. After a patient has dosed, they must immediately leave the clinic and surrounding area.
  • Patients may not arrive for treatment before 15 minutes of scheduled sessions or groups. Unless patient is physically challenged, they may not wait on clinic property for a ride. Patients who are placed on a physically challenged status must have a letter stating such from their doctor.
  • Any patients found to linger or loiter will be brought into the clinic to sign a non-compliance contract. Patients are not allowed to loiter at McDonald's, Mary's or Galaxy restaurants. Any patient refusing to sign a contract will be identified to Administration and will receive a 10mg decrease in their daily dose. This contract will place the patient on a probation period. Any and every violation of noncompliance will result in a reduction of the patient's methadone dose.
  • ANY PATIENT WHO IS ON PROBATION AND OR ON CONTRACT CANNOT GET AN INCREASE IN THEIR METHADONE DOSE UNLESS THERE IS WRITTEN APPROVAL BY THE EXECUTIVE DIRECTOR OR ASSISTANT DIRECTOR. To ensure that this policy is met, all contracts must be placed in the medical section of the patient file next to the green sheet. If a physician deems an increase is necessary for any patient, the physician should consult with Administration prior to increasing the patient's dose.
  • I have read and understand the "Dose and Go" Policy.

  • Star Center, Inc. Telehealth Consent Form

  • I consent to receive telehealth services from Star Center, Inc.

  • 1. I understand that this is out of necessity and an abundance of caution due to the Coronavirus (Covid-19) pandemic. This will continue until such time that we are able to meet in person, or could continue, depending on the particular circumstance.
    2. I understand that telehealth has potential benefits including, but not limited to, easier access to care and it has been effective in treating a wide range of disorders.
    3. I understand that it is my obligation to notify my counselor of my location at the beginning of each treatment session. If I, for some reason, change my location during the session, I must notify my counselor of this change in location during the session.
    4. I agree that I will not record either through audio or video any of the session, unless my counselor and the counselor agree to such recording.
    5. I understand that there are potential risks to using Telehealth technology, including, but not limited to, interruptions, unauthorized access, and technical difficulties. I understand that my counselor is not responsible for any technology problems of which my counselor has no control over.
  • By signing this document, I acknowledge:
  • 1. Telehealth is NOT an emergency service. In the event of an emergency, I will use a phone to call 9-1-1 and/or other appropriate emergency contacts.
    2. I recognize that my counselor may need to notify emergency personnel in the event he/she feels there is a safety concern, including, but not limited to, a risk to self/others or my counselor is concerned that immediate medical attention is needed.
    3. Telehealth facilitates counseling sessions and is not, itself, a source of healthcare, medical advice, or care.
    4. I understand that the same fee rates apply for telehealth as apply for in-person treatment.
    5. I understand that either I or my counselor can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I understand there may be no other treatment alternative available.
  • Consent for the release of Confidential Alcohol or Drug Treatment and Tb, STD, HIV/AIDS
    information to comply with disease reporting requirements.

  • I, authorize Star Center, Inc., to disclose to the appropriate Health Department the following information (nature of information to be limited to communicable disease):

  • 1. Information required by State of Michigan Law regarding diagnosis and treatment for:

  • 1. Information required by the State of Michigan Law regarding and treatment for:

    • HIV Infection
    • STI (Sexually transmitted infections)
    • TB (Tuberculosis)

  • 2. My name and other personal identifying information, if required, to be reported by State Law.

  • 3. Information about my status as a patient in alcohol or drug treatment as required by State Law.

  • The purpose of this disclosure is to provide treatment for abnormal laboratory or ppd Tb test.

  • I understand that my records are protected under Federal Regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 45 CFR Parts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that HIV/AIDS and Tb related information about me is protected by State Law. 

  • Privacy Practices Acknowledgement

  • HIPAA ACKNOWLEDGEMENT

  • Our Notice of Privacy practices pertain to the Health Insurance Portability and Accountability Act (HIPAA) gives you information about how we may use and disclose health information about you.
  • By signing this form, you are acknowledging that you have reviewed and understand the Notice of Privacy practices.

  • STAR CENTER, INC.

  • STAR CENTER INC.
    COMMUNICABLE DISEASE RISK ASSESSMENT FORM TB; HEPATITIS C & SYPHILIS

  • Patients who report a history of substance abuse are at greater risk of developing serious communicable diseases. Please answer the following questions to determine if you may need further health assessment.

  • General Health Questions:

  • Have you seen a doctor or other healthcare provider in the past three months?*
  • Do you need help with a referral to a Primary Care Doctor?*
  • Have you missed your last two periods?*
  • Do you think you are pregnant?*
  • Are you in prenatal care?*

  • Tuberculosis (TB)

  • Do you tire easily?*
  • Have recently you lost weight without trying?*
  • Have you noticed a loss of appetite?*
  • Have you had a cough for more than three weeks?*
  • Do you ever cough up blood?*
  • Have you noticed your glands are swollen?*
  • Have you recently had a fever or chills lasting more than 3 days?*
  • Have you had close contact with someone that might have TB?*

  • Human Immunodeficiency Virus (HIV)

  • Have you engaged in unprotected sexual intercourse with one or more partners whose HIV status is unknown?*
  • Have you engaged in sexual activity with individuals who have been identified as HIV positive?*
  • Have you shared needles or are injecting "works" with other individuals?*
  • Have you experienced forms of blood-to-blood contact where you have questions about your HIV status, i.e. blood transfusion, dental contact, hemophilia treatment, etc.?*

  • Hepatitis A and C

  • Have you injected illegal drugs or shared needles even once?*
  • Have you snorted any drugs or shared the straw/dollar bill?*
  • Have you had a tattoo or body piercing where the needle or dye was shared?*
  • Have you been told you have elevated liver enzymes or liver disease?*

  • Syphilis & Other STD's

  • Have you had sexual experience with someone who has had a recent sexually transmitted disease?*
  • Have you or anyone you've had sex with experienced a sore or ulcer on their penis or vagina?*
  • Do you have a discharge from the penis?*
  • Discharge is different from what you usually have?*
  • Pain with vaginal sex*
  • Have you or anyoe you've had sex with experience burning on urination?*
  • Have you had more than one sex partner in six months?*
  • Have you had man-to-man sexual encounters?*
  • Are you pregnant?*
  • If at risk, by staff signature below you are confirming that you have identified health referral resources for high-risk behaviors identified above, and have given the information to the client.
  • Client identifies that he/she: Plans to or Does not plan to follow up on these referrals. (Check one)

  • Star Center, Inc.

  • ADVANCE DIRECTIVES and APPEALS DOCUMENT

  • Advance directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes.

    The two most common advance directives for health care are the living will and the durable power of attorney for health care.

    - Living will: A living will is a legal document that tells doctors how you want to be treated if you cannot make your own decisions about emergency treatment. In a living will, you can say which common medical treatments or care you would want, which ones you would want to avoid, and under which conditions each of your choices applies. 
    - Durable power of attorney for health care: A durable power of attorney for health care is a legal document that names your health care proxy, a person who can make health care decisions for you if you are unable to communicate these yourself. Your proxy, also known as a representative, surrogate, or agent, should be familiar with your values and wishes. A proxy can be chosen in addition to or instead of a living will. Having a health care proxy helps you plan for situations that cannot be foreseen, such as a serious car accident or stroke. 

  • I have received Information regarding Advance Directives.
  • I need to complete an Advance directive at the time*

  • I have received a copy of the Grievance Appeal Options

  • Star Center, Inc

    Client Notice of Privacy Practices

    The client confidentiality of Alcohol and Drug Abuse clients' records maintained by this program is protected by Federal Law. Generally, the program may not divulge the identity of a client to anyone outside of the agency unless the disclosure is:

    1. Permitted by the client with written consent.
    2. Required by a court order.
    3. Made to medical personnel in a medical emergency.
    4. Made to complete treatment, payment, and health care operations to clinicians, health plans, and insurers or qualified personnel for research, audit or program evaluation.

    Violation of the Federal Law and Regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal Regulations.

    Federal Law and Regulations do not protect any information about a crime committed by a client either at the program or against any person who works for the program or about any threat to commit a crime.

    Federal Law and Regulations do not protect any information about suspected child abuse or neglect from being reported under State Law to appropriate Stator Local Authorities.

    Records related to treatment cannot be used to provide testimony about your information in any civil, administrative, criminal, or legislative proceedings against you without your written consent, a subpoena, or a court order.

    We may use or share your information to respond to legal proceedings against our program based on a court order and you may not be notified in advance.

    Prohibition on Re-disclosure of Client Information in Alcohol or Drug Abuse Treatment

    This notice accompanies a disclosure of information concerning a client in Alcohol or Drug Abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by 42 CFR Part 2. The Federal Rules prohibit us from making any further disclosure of this information unless this disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

  • STAR CENTER, INC.

    Consent to Participatoin in Opioid Pharmacotherapy Treatment

  • NAME OF PROGRAM MEDICAL DIRECTOR: Dr. Saleh Ghaith, M.D.

    I hereby authorize and give voluntary consent to Star Center, Inc., and its medical personnel to dispense and administer opioid pharmacotherapy (including Methadone or Buprenorphine) as part of the treatment of my addiction to opioid drugs. Treatment procedures have been explained to me, and I understand that this will involve my taking the prescribed opioid drug at the schedule determined by the program physician in accordance with Federal and State regulations. It is been explained that, like all other prescription medications, opioid treatment medications can be harmful if it is not taken as prescribed. Overdoses of methadone are lethal, as can combinations of methadone and other drugs including, alcohol. I further understand that opioid treatment medications produce dependence and, like most other medications, may produce side effects. Possible side effects have been explained to me.

    I understand that it is important to me to inform any medical provider who may treat me for any medical problem that I am enrolled in an opioid treatment program so that the provider is aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing medications that might affect my opioid pharmacotherapy or chances my chances of successful recovery from addiction.

    I understand that I may withdraw voluntarily from this treatment program and discontinue the use of the medications prescribed at any time. Should I choose this option, I understand I will be offered medically supervised withdrawal.

    I further authorize provision of the following: diagnostic assessment, individual and group counseling, medication review and monitoring. My participation is voluntary; I understand that this program follows person-centered planning guidelines and that my treatment plan will be individualized to meet my needs and goals and I will participate in the development of my treatment plan.

    For Female Patients of Childbearing Age: There is no evidence that methadone pharmacotherapy is harmful during pregnancy. If I am, or become pregnant, I will inform the program immediately so that I can receive appropriate care and referrals.
    This release allows Star Center, Inc. to contact other methadone treatment programs within a 200-mile radius to ensure that I am not dually enrolled.

     

     

     

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • To expidite the admission process you may upload your identification and insurance information.

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