• RFG

    Helping You Pursue Excellence 2.0 (H20) Client Intake Packet

    Behavioral Health Services Enrollment

  • Welcome — Read Before Proceeding

  • What You're About to Complete

    Please set aside approximately 30–45 minutes to complete this packet in full. We recommend completing it in one sitting.

  • Important Instructions


    Please read carefully:

    All client information fields must be completed with the information of the person receiving services — this is the individual who will be attending therapy or programming.

  • What You'll Need

    • Client's date of birth and Social Security Number
    • Insurance information
    • Valid photo ID
    • Emergency contact information

  • Privacy & Confidentiality

    Your privacy matters to us. All information collected through this form is Protected Health Information (PHI) and is safeguarded in accordance with HIPAA and 42 CFR Part 2. Your information will not be shared without your written authorization, except in limited circumstances required by law. Only authorized staff directly involved in the client's care will have access to this information. We take every measure to ensure your data is stored securely and handled with the highest level of confidentiality.

  • Client Demographics

  • Client Date of Birth*
     / /
  • Assigned Sex at Birth*
  • Veteran Status*
  • Does the client have a disability?*
  • Format: (000) 000-0000.
  • What type of phone is this?*
  • Voice/Text Messages OK?*
  • Format: (000) 000-0000.

  • Does the Client have a Guardian?*
  • Format: (000) 000-0000.

  • Primary Insurance

  • How to find your Member ID:

    Your Medicaid Member ID is located on the front of your insurance card.

    It is a 12-digit number and may be labeled "Member ID," "Medicaid #," "ID Number," or "Policy Number." If you have a Medicaid card, it is the number directly below your name. If you cannot locate it, contact your insurance company's member services number on the back of your card.

    You must provide your Medicaid ID to receive services. If you have a secondary insurance company please enter it below in the Secondary Insurance section.

  • Secondary Insurance (If Applicable)

  • Past Mental Health Treatment

  • Has the client ever received counseling or psychotherapy in the past?*

  • Expectations of Treatment

  • Behavioral Symptoms Checklist

    Please Check All That Apply
  • Check all that apply to the Client*
  • What programs or services are you interested in receiving with us?*
  • Does the client have any immediate, critical/urgent needs?*

  • Health History Questionnaire

  • Has the client or a family member had any of the following health problems? 

  • Physical Health Conditions
    Rows
  • Mental/Behavioral & Other Conditions
    Rows

  • Medical History

  • Medical Hospitalization / Surgical Procedures

  • Has client had medical hospitalization/surgical procedures in the last three years?*

  • Allergies / Drug Sensitivities

  • Does the client have any food or drug allergies/sensitivities?*

  • Last Physical Examination

  • Client Symptoms in the Past 30 Days

  • Check all that apply*

  • Immunizations

  • Are the client's immunizations up to date?*

  • Pain Screening

  • Does pain currently interfere with the client's activities?*

  • Maternal Health History

  • Pregnancy History

  • Are you currently pregnant?*
  • Receiving prenatal healthcare?*
  • ¸Are you currently breastfeeding?*

  • Nutrition Info

  • Client Nutritional Screening (within the last 30 days)

  • Eating (check all that apply):*
  • Hydration (check all that apply):*
  • Appetite (check all that apply):*
  • Additional concerns (check all that apply):*
  • Where does the Client eat their meals? (check all that apply):*

  • Medication History

  • Current Medications

  • Is the client currently taking any medications?*

  • Substance Use History

  • Does the Client currently use or has ever used alcohol or recreational drugs?*

  • Substance Use History

  • Please check all substances used (past or present):*
  • Are you currently using any substances?*
  • Have you ever received treatment for substance use?*

  • Informed Consent for Assessment and Treatment

  • I understand that I am eligible to receive a range of services from my provider. The type and extent of services I receive will be determined following an initial assessment and thorough discussion with me. The assessment process aims to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

    I understand that I have the right to ask questions throughout the course of treatment and may request an outside consultation. (I also understand that my provider may provide additional information about specific treatment issues and treatment methods on an as-needed basis during the course of treatment and that I have the right to consent to or refuse such treatment.) I understand that I can expect a regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment and the review process. No promises have been made as to the results of this treatment or any procedures utilized within it. I further understand that I may stop treatment at any time, but agree to discuss this decision first with my provider.

    I am aware that I must authorize my provider, in writing, to release information about my treatment but that confidentiality can be broken under certain circumstances of danger to myself or others. I understand that once information is released to insurance companies or any other third party, my provider cannot guarantee that it will remain confidential. When consent is provided for services, all information is kept confidential, except in the following circumstances:

     

    • When there is a risk of an imminent danger to myself or another person, my provider is ethically bound to take necessary steps to prevent such danger.
    • When there is suspicion that a child or elder is being sexually or physically abused, or is at risk of such abuse, my provider is legally required to take steps to protect the child and to inform the proper authorities.
    • When a valid court order is issued for medical records, my provider is bound by law to comply with such requests.

     

    While the summary is designed to provide an overview of confidentiality and its limits, it is important that you read the Notice of Privacy Practices which is provided to you for more detailed explanations, and discuss with your provider any questions or concerns you may have.

    By my signature below, I voluntarily request and consent behavioral behavioral health assessment, care, treatment, or services and authorize my provider to provide such care, treatment or services as are considered necessary and advisable. I understand that the practice of behavioral Health assessment is not an exact science and acknowledged that no one has made guarantees or promises as to the results that I may receive. By signing this informed consent to treatment form, I acknowledge that I have both read and understood the terms and information contained in herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

  • Client Date of Birth*
     / /
  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Release of Information Consent

  • Would you like to authorize the release of your protected health information to anyone? This includes any individuals who will be involved in your treatment (such as family members or a spouse) as well as outside providers (such as doctors, psychiatrists, or therapists).*

  • Release of Information Consent

  • I hereby authorize Helping You Pursue Excellence 2.0 (H20) to obtain information from, disclose information to, or exchange information with the authorized organization or individual noted below.

  • Client Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Purpose of this Authorization (checkbox, select all that apply):*
  • The specific information to be disclosed (check each specific item):*
  • Purpose of Disclosure:*
  • Do you need to add another authorized individual or organization?*

  • Confidentiality Rules:

    This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42 CFR, part two. General authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.

  • This authorization and consent to release protected health information will automatically expire six months (180 days) after the date of the authorization unless:
  • Expiration Date
     / /
    2 digit month, 2 digit day, 4 digit year
    • I understand that if the recipient of the above information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed by such recipients and will likely no longer be protected by federal privacy regulations.
    • I understand that Helping You Pursue Excellence 2.0 (H20) cannot control the recipient's use of the disclosed information.
    • I understand that authorizing the use or disclosure of the above information is voluntary.
    • I understand that Helping You Pursue Excellence 2.0 (H20) will not condition treatment, payments, enrollment, or eligibility for benefits on the execution of this authorization.
    • I understand that I can revoke this information at any time, except to the extent the action has been taken by Helping You Pursue Excellence 2.0 (H20) and reliance on this authorization, and that the revocation must be signed and dated by me. Upon the location of this authorization, for the release of information shall immediately cease.
    • This disclosure may include paper, oral, and electronic interchange.

  • Signatures

  • By signing below, I confirm that all information provided in this form is true and accurate to the best of my knowledge. I have read and agree to all consent statements on the previous page. I understand that providing false information may delay or prevent services.

  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Release of Information Consent

  • I hereby authorize Helping You Pursue Excellence 2.0 (H20) to obtain information from, disclose information to, or exchange information with the authorized organization or individual noted below.

  • Client Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Purpose of this Authorization (checkbox, select all that apply):*
  • The specific information to be disclosed (check each specific item):*
  • Purpose of Disclosure:*
  • Do you need to add another authorized individual or organization?*

  • Confidentiality Rules:

    This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42 CFR, part two. General authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.

    This authorization and consent to release protected health information will automatically expire six months (180 days) after the date of the authorization unless:

  • Expiration Date
     / /
    2 digit month, 2 digit day, 4 digit year
    • I understand that if the recipient of the above information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed by such recipients and will likely no longer be protected by federal privacy regulations.
    • I understand that Helping You Pursue Excellence 2.0 (H20) cannot control the recipient's use of the disclosed information.
    • I understand that authorizing the use or disclosure of the above information is voluntary.
    • I understand that Helping You Pursue Excellence 2.0 (H20) will not condition treatment, payments, enrollment, or eligibility for benefits on the execution of this authorization.
    • I understand that I can revoke this information at any time, except to the extent the action has been taken by Helping You Pursue Excellence 2.0 (H20) and reliance on this authorization, and that the revocation must be signed and dated by me. Upon the location of this authorization, for the release of information shall immediately cease.
    • This disclosure may include paper, oral, and electronic interchange.

  • Signatures

  • By signing below, I confirm that all information provided in this form is true and accurate to the best of my knowledge. I have read and agree to all consent statements on the previous page. I understand that providing false information may delay or prevent services.

  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Release of Information Consent

  • I hereby authorize Helping You Pursue Excellence 2.0 (H20) to obtain information from, disclose information to, or exchange information with the authorized organization or individual noted below.

  • Client Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Purpose of this Authorization (checkbox, select all that apply):*
  • The specific information to be disclosed (check each specific item):*
  • Purpose of Disclosure:*

  • Confidentiality Rules:

    This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42 CFR, part two. General authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.

    This authorization and consent to release protected health information will automatically expire six months (180 days) after the date of the authorization unless:

  • Expiration Date
     / /
    2 digit month, 2 digit day, 4 digit year
    • I understand that if the recipient of the above information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed by such recipients and will likely no longer be protected by federal privacy regulations. I understand that Helping You Pursue Excellence 2.0 (H20) cannot control the recipient's use of the disclosed information.
    • I understand that authorizing the use or disclosure of the above information is voluntary. I understand that Helping You Pursue Excellence 2.0 (H20) will not condition treatment, payments, enrollment, or eligibility for benefits on the execution of this authorization.
    • I understand that I can revoke this information at any time, except to the extent the action has been taken by Helping You Pursue Excellence 2.0 (H20) and reliance on this authorization, and that the revocation must be signed and dated by me. Upon the location of this authorization, for the release of information shall immediately cease.
    • This disclosure may include paper, oral, and electronic interchange.

  • Signatures

  • By signing below, I confirm that all information provided in this form is true and accurate to the best of my knowledge. I have read and agree to all consent statements on the previous page. I understand that providing false information may delay or prevent services.

  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Client Responsibilities

  • Scheduled Appointments

  • • If you are late to any scheduled session:

    The client will have a 15-minute grace period. After 15 minutes of the scheduled appointment, you MUST reschedule. Your session will still end on time if you arrive at the 15-minute grace period mark.

    • If you need to cancel or reschedule:

  • You must provide Helping You Pursue Excellence 2.0 (H2O) with a 24-hour notice if client is unable to attend the scheduled appointment.

  • Missed Appointments

  • • No show:

  • Private Insured - will be charged $10 per Helping You Pursue Excellence 2.0 (H2O)'s policy


    Medicaid Insured - No payment

  • • If you miss 3 consecutive appointments:


    Services will be terminated and you will be referred to another agency.

  • *If arranged with provider, the above will not apply*

  • Private Clients

  • • If deductible is not met:

    Client will pay based on a sliding scale fee for the initial assessment and Individual Therapy Sessions.

    Client and Helping You Pursue Excellence 2.0 (H2O) representative will discuss copayment details that are specific to the client.

  • Violent/Aggressive Behavior

  • • If a client displays aggressive, alarming, and intolerable behavior towards group peers and or staff, they will be asked to be dismissed. If non-compliant we will call the police to have the client removed and revisit their case within 24 hours of the event. We will revisit their case to determine whether prolonged care or transition to a higher level of care.


    • It is a person-served's responsibility to behave respectfully towards all Helping You Pursue Excellence 2.0 (H2O) staff (cursing, threatening, yelling/shouting, or rude comments WILL NOT BE TOLERATED).

  • Urinalysis

  • • Per Ohio treatment law and Helping You Pursue Excellence 2.0 (H2O) policy, refusal or failure to submit your analysis at the time of random drug screens will be documented as a positive screen.

  • Professional Records

  • • Clients records are maintained in a secure location in the office.
    • Clients also have the right to request that a copy of your file may be made available to any other healthcare provider at your written request.
    • Clients have full access to their personal file.

  • Grievances

  • • If you are unhappy with what is happening in therapy or any other services provided to you we hope you will talk with us so that we can respond to your concerns.

  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Client Served Rights

  • Helping You Pursue Excellence 2.0 (H20) persons served has the following rights:

  • • The right to be treated with consideration and respect for personal dignity, autonomy, and privacy;

    • The right to reasonable protection from physical, sexual, or emotional abuse and inhumane treatment; neglect.

    • The right to receive services in the least restrictive, feasible environment;

    • The right to participate in any appropriate and available service that is consistent with any individual treatment plan (ITP), regardless of the refusal of any other service, unless the service is a necessity for clear treatment reasons and requires the person's participation;

    • The right to give informed consent or to refuse any service, treatment, or therapy, including medication absent an emergency;

    • The right to participate in the development, review, and revision of one's individualized treatment plan and to receive a copy of it;

    • The right to freedom from a necessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others.

    • The right to be informed and the right to refuse any unusual, or hazardous treatment procedure;

    • The right to be advised in the right to refuse observation by others and by techniques such as One Way vision mirrors, tape recorders, video recorders, television, movies, photographs, or other audio and visual technology. This rate does not prohibit an agency from using closed-circuit monitoring to observe seclusion rooms for common areas, which does not include bathrooms or sleeping areas;

    • The right to confidentiality of communications and personal identifying information within limitations and requirements for disclosure of client information under the state and federal laws and regulations;

    • The right to have access to one's person-served record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction;

    • The right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unable or not necessary.

    • The right to be informed of the reason for denial of a service;

    • The right to be verbally informed of all person-served rates, and to receive a written copy upon request;

    • The right to exercise one's rights without appraisal, except that no right extends so far as to supersede health and safety considerations;

    • The right to file a grievance;

    • The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested;

    • The right to be informed of one's condition.

    • The right to consult with an independent treatment specialist or legal counsel that one's expense.

    • The right to be protected from financial exploitation, and humiliation.

  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Notice of Privacy Practices

  • Effective April 29, 2015

    This notice describes how medical information about you may be used and disclosed and how you get access to this information. Please review this notice carefully.

    Your health record contains personal information about you and your health. This information about you that may identify you and relates to your past, present, or future physical or mental health or condition and related healthcare practices is referred to as protected health information ("PHI"). This notice of privacy practices describes how your provider may use and disclose your PHI by applicable law. It also describes your rights regarding how you may gain access and control of your PHI.

    Under the Health Insurance Portability and Accountability Act of 1996 ("HIPPA"), your provider is required to maintain the privacy of PHI and to provide you with notice of his or her legal duties and privacy practices concerning PHI. Your provider is required to abide by the terms of this Notice of Privacy Practices. The provider reserves the right to change the terms of his Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that your provider maintains at that time. Your provider will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or by providing one to you at your next appointment.

    HOW YOUR PROVIDER MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

    For Treatment: Your PHI may be used and disclosed to those who are involved in care to provide, coordinate, or manage your healthcare treatment and related services. This includes consultation with clinical supervisors or other treatment team members. Your provider may disclose PHI to any other consultant only with your authorization.

    For Payment: Your provider may use and disclose PHI so that he or she can receive payment for the treatment services provided to you. Examples of payment-related activities are: deciding eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, only the minimum amount of PHI necessary for purposes of collection will be disclosed.

    For Healthcare Operations: Your provider may use or disclose, as needed, your PHI to support his or her business activities including, but not limited to, quality assessment activities, licensing, and conducting or arranging other business activities. For example, your PHI may be shared with third parties that perform various business activities provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. Your PHI may be used to contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services.

    Required by Law: Under the law, your provider must test disclosures of your PHI to you upon your request. In addition, disclosures must be made to the secretary of the Department of Health and Human Services to investigate or determine compliance with the requirements of the privacy rule.

    Without Authorization: Applicable law and ethical standards permit your provider to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

    • Required by law, such as mandatory reporting of child abuse neglect, or elder abuse, or mandatory government agency audits or investigations.
    • Required by Court Order.
    • Necessary to prevent or lessen serious and eliminate threats to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

    Verbal Permission: Your provider may use or disclose your information to family members who are directly involved in your treatments with your verbal permission.

    With Authorization: Use and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

    YOUR RIGHTS REGARDING YOUR PHI

    You have the following rights regarding PHI maintained about you to exercise any of these rights, please submit your request in writing to your provider.

    Right of Access to Inspect and Copy. In most cases, you have the right to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. Your provider may charge a reasonable, cost-based fee for copies.

    Right to Amend. If you feel that the PHI your provider has about you is incorrect or incomplete, you may ask for it to be amended, although your provider is not required to agree to the amendment.

    Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures that your provider makes of your PHI. Your provider may charge you a reasonable fee if you request more than the accounting in any 12-month period.

    Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI treatment, payment, or healthcare operations. Your provider is not required to agree to your request.

    Right to Request Confidential Communication. You have the right to request that your provider communicate with you about medical matters in a certain way or at a certain location.

    Right to Copy of This Notice. You may ask your provider for a paper copy of this notice at any time.

    COMPLAINTS

    If you believe your privacy rights have been violated, you may submit a complaint with the federal government. Filing a complaint will not affect your right to further treatment or further treatment. To file a complaint with the federal government please contact:

     

    Secretary of the U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Washington, DC 20201
    (202) 619-0257

     

    ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    I acknowledge receipt of the Notice of Privacy Practices, which explains my rights and limits on ways my provider may use or disclose personal health information to provide service.

  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Media Consent

  • Media & Film Release Consent

  • By signing this consent form, I authorize Helping You Pursue Excellence 2.0 (H20) to capture, reproduce, distribute, and otherwise use photographs, videos, audio recordings, and any other form of media material featuring myself or my child for educational, informational, social media, marketing, and promotional purposes. This authorization extends to use in print materials, digital platforms, websites, social media accounts, newsletters, presentations, and any other publications or media channels associated with H20.

     

    From time to time, Helping You Pursue Excellence 2.0 (H20) may show films related to topics discussed during group sessions. The purpose of showing these films is to provide clients with a deeper awareness and understanding of the subject matter being addressed. These films may contain mature content, including strong language and graphic scenes. Clients have the option to not participate in watching the film at any time.

  • Do you consent?*
  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Discharge Notification Preferences

  • A discharge summary will be provided at the time of discharge. In the event that we are unable to reach you directly, please select your preferred method of contact for discharge notification:*

  • Please sign verifying you understand the preferred method of contact in the event of discharge where the agency cannot reach you. I understand that by signing below, I have agreed to have Helping You Pursue Excellence 2.0 (H20) use my preferred method of contact checked above in the event I am unable to be reached.

  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year

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