• SERVICE INITIATION: CLIENT INFORMATION

  • CLIENT IDENTITY

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

  • DEMOGRAPHICS & SCREENING QUESTIONS

  • Does the Client Identify as LGBTQA+?*
  • Is the client pregnant?*
  • Does the client have children under 18 years old?*
  • Is the client an IV drug user?*
  • Is the client homeless - no fixed address?*
  • Has the client been civilly committed?*
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • GLOBAL APPRAISAL OF INDIVIDUAL NEEDS (GAIN-SS)

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

  • IDScr

  • When was the last time you have significant problems...
  • With feeling very trapped, lonely, sad, blue, depressed or hopeless about the future? (Select one option)*
  • Sleep trouble, such as bad dreams, sleeping restlessly, or falling asleep during the day? (Select one option)*
  • Feeling very anxious, nervous, tense, scared, panicked, or like something bad was going to happen? (Select one option)*
  • With becoming very distressed and upset when something reminded you of the past? (Select one option)*
  • With thinking about ending your life or committing suicide? (Select one option)*
  • Seeing or hearing things that no one else could see or hear or feeling that someone else could read or control your thoughts? (Select one option)*

  • EDScr

  • When was the last time you did the following two or more times...
  • Lied or conned to get things you wanted or to avoid having to do something? (Select one option)*
  • Had a hard time paying attention at school, work, or home? (Select one option)*
  • Had a hard time listening to instructions at school, work, or home? (Select one option)*
  • Were a bully or threatened other people? (Select one option)*
  • Started physical fights with other people? (Select one option)*
  • Tried to win back your gambling losses by going back another day. (Select one option)*

  • SDScr

  • When was the last time that you...
  • You used alcohol or other drugs weekly or more often? (Select one option)*
  • You spent a lot of time either getting alcohol or other drugs, using alcohol or other drugs, or recovering from the effects of alcohol or other drugs (e.g., feeling sick)? (Select one option)*
  • You kept using alcohol or other drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people? (Select one option)*
  • Your use of alcohol or other drugs caused you to give up or reduce your involvement in activities at work, school, home, or social events? (Select one option)*
  • You had withdrawal problems from alcohol or other drugs like shaky hands, throwing up, having trouble sitting still or sleeping, or you used any alcohol or other drugs to stop being sick or avoid withdrawal problems? (Select one option)*

  • CVScr

  • When was the last time that you...
  • Had a disagreement in which you pushed, grabbed, or shoved someone? (Select one option)*
  • Took something from a store without paying for it? (Select one option)*
  • Sold, distributed or helped to make illegal drugs? (Select one option)*
  • Drove a vehicle while under the influence of alcohol or illegal drugs? (Select one option)*
  • Purposely damaged or destroyed property that did not belong to you? (Select one option)*
  • GLOBAL APPRAISAL OF INDIVIDUAL NEEDS (GAIN-SS)
  • Today's Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Page 1 of 1

  • Elite Recovery, LLC

    Assessment Financial Agreement and Consent Form & Assignment of Benefits & Financial Responsibility
  • By signing this form, I agree to the following:

    Insurance Payments: I authorize my insurance company to pay benefits directly to Elite Recovery, LLC.

    Financial Responsibility: I am responsible for any charges not covered by insurance, including deductibles, co-pays, and coinsurance. If my treatment is not covered, I am responsible for the entire bill.

    Medicare: Elite Recovery, LLC is not a Medicare provider. If I am or become Medicare-eligible during treatment, I will be responsible for all charges.

    Insurance Checks Sent to Me: If my insurance company sends payment to me directly, I will turn it over to Elite Recovery, LLC.

  • Assessment Fees

  • Chemical Health Assessment:
        Insurance: Billed according to contracted rate
        Out-of-Pocket Cost: $180

    Mental Health Diagnostic Assessment:
        Insurance: Billed according to contracted rate
        Out-of-Pocket Cost: $225

    If I choose to use insurance, claims will be submitted on my behalf. I understand that I am ultimately responsible for any charges not covered by my insurance, including deductibles, co-pays, and co-insurance.

    Elite Recovery will not complete a repeat chemical health assessment within 30 days of a prior assessment unless I elect to pay out-of-pocket.

  • Billing & Collections

    • Any balance over 90 days becomes my responsibility and is due immediately unless other arrangements are made.
    • Accounts past 90 days may be sent to collections. I will be responsible for the full balance plus collection costs, attorney fees, and a collection fee of 30% of the outstanding balance.
    • My chemical health evaluation may not be considered complete until my account is paid in full.

    Questions? Contact: Ciera Spencer, Utilization Review Specialist – 612-444-6544

  • Electronic Communication Consent

  • Elite Recovery may use email and text messaging for:
    • Sharing forms and documents
    • Scheduling, appointment reminders, and updates
    • Other limited, necessary communication

    We take steps to protect your confidentiality, but electronic communication carries a risk of unauthorized access. These communications should be used mainly for scheduling, not clinical discussions.

    You may withdraw consent at any time in writing (services will still be provided).

    You are responsible for protecting your information on your own devices (use passwords, multi-factor authentication, etc.)
  • Today's Date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • ELITE RECOVERY

  • AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

    If you have a legal representative, collateral contact, or another individual or organization that needs a copy of your assessment, please complete the following Release of Information (ROI) form for each applicable person or organization.

  • A copy of this will be considered as valid as the original

  • PROGRAM LOCATIONS (SAINT PAUL, MN 55105)
    1137 Grand Ave • 1145 Grand Ave • 937 Grand Ave • 957 Grand Ave • 840 Grand Ave
  • born on
     - -
    2 digit month, 2 digit day, 4 digit year
  • authorize Elite Recovery, LLC to:

  • THE INDIVIDUAL AND/OR AGENCY INDICATED BELOW:

  • Format: (000) 000-0000.

  • I AUTHORIZE RELEASE OF THE FOLLOWING PRIVATE HEALTH INFORMATION:

  • Health Information Options
  • By law, the following information requires special consent. You must request each specifically on separate releases:
  • Special Consent Items
  • REASON(S) FOR RELEASING INFORMATION:
  • SHARED FORMATS:
  • This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). 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 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. I understand that Elite Recovery, LLC cannot prevent the re-disclosure of records released as a result of this request and that the records may not be subject to privacy rule protections; therefore Elite Recovery, LLC is released from any and all liability resulting from re-disclosure.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Elite Recovery, LLC - Authorization for Release of Protected Health Information
  • Should be Empty: