Client Demographics

Participant Rights for Outpatient Services
Name*

First NameLast Name
All participants receiving outpatient services shall have and enjoy all constitutional rights of all citizens of the State of Oklahoma and
the United States, unless abridged through the process of law by a court of competent jurisdiction. Each facility providing outpatient
mental health services shall insure participants have the rights specified as follows:

1. All participants have the right to be treated with respect and dignity. This shall be construed to protect human dignity and respect for human dignity;
2. Each participant has the right to receive services in a safe, sanitary, and humane environment;
3. Each participant has the right to receive services in a humane psychological environment protecting them from harm, abuse, or neglect;
4. Each participant has the right to receive services in an environment which provides privacy, promotes personal dignity, and provides the opportunity to improve his/her functioning;
5. Each participant has the right to receive services without regard to race, religion, sex, degree of disability, handicapping conditions, legal status, and/or ability to pay for services;
6. No participant shall ever be neglected or sexually, physically, verbally, or otherwise abused;
7. Each participant has the right to prompt, competent, appropriate treatment and an individualized treatment plan:
A. The participant shall have the opportunity to participate in his/her treatment and treatment planning, and may consent, or refuse to consent, to the proposed planning;
B. The participant’s rights to consent, or refuse to consent, may be abridged for those judged incapacitated by a court of competent jurisdiction and in an emergency situation defined by law;
C. When the participant permits, the family /significant others may be involved in treatment and treatment planning.
8. The records of each participant shall be treated in a confidential manner;
9. Each participant has the right to refuse to participate in any research project or medical experiment without informed
consent, as defined by law. A refusal to participate shall not affect the services available to the client;
10. A participant may voluntarily participate in work therapy, and shall be paid just compensation for such work;
11. Each participant has the right to request the opinion of an outside medical or psychiatric consultant, at the expense of the participant, and the right to an internal facility consultation, at no cost;
12. Each participant has the right to assert grievances with respect to any alleged infringement of those stated, or any other subsequently statutorily granted rights;
13. No participant shall ever be retaliated against, or subject to, any adverse conditions or treatment solely or partially because of having asserted his/her rights as afore stated in this section;

I, the undersigned, have read, or have had read to me, the above rights. I acknowledge that the staff of Improving Lives
Counseling Services, Inc. has explained my rights to me.
Client (14 or older) Signature*

Clear
Date:

MonthDayYear
Date
Parent or Guardian Signature:*

Clear
Date:

MonthDayYear
Date
CLICK ON NEXT

Procedures For Client Grievances and Other Issues
Client Name*

First NameLast Name
The Agency (Improving Lives Counseling Services, Inc wishes to maintain an open line of communication, giving the client adequate opportunity to express opinions, recommendations, and complaints.

Who May File A Grievance: Any client under the care of any agency or anyone interested in the welfare of a client receiving care at any agency (e.g. relative, foster parent, DHS Caseworker) may at his/her discretion provide in writing any opinion or recommendation.

What Complaints Are Considered: The complaint may be about any rule, policy, action, decision, or condition made or permitted by any agents or any other person paid by the agency to care for a client of any agent.

When a Grievance May Be Filed: It is important that grievances be filed as soon as possible. Grievances should be filed within five (5) days of the action grieved.

How To File A Grievance: Request a Grievance Form from any staff member. Write your complaint on the form and include your ideas on a resolution of the problem. Sign the form and return it to the Grievance Coordinator or the Program Director. You may request assistance from the agency employee or another person in getting the form, writing, and/or filing the grievance. The Executive Director at his/her discretion may call a meeting of the staff to give the opinion/grievance due consideration. Any grievance or complaint deemed to be of a serious nature will call for action by the Executive Director with the arrangements for a meeting of a staff committee. This will occur within ten (10) working days. The committee may take any action as deemed necessary. The client may request a written report from the committee, which shall be provided within thirty (30) days from the filing of the grievance or complaint. After your grievance/complaint is filed, an attempt will be made, with your participation, to resolve the problem. You have the right to file grievances, to receive a written response to your complaint, and to appeal if you are not satisfied with the response. If any person attempts to deny you these rights or penalize you for filing a grievance, contact the Program Director.

To Further Pursue A Grievance you may wish to contact DHS/Client Advocacy Officer at:

Advocacy Office 900 E. Main (P.O. Box 151) Norman, OK 73070 Phone: 405-573-6605

For more information about Grievance Procedure, contact the Director in your area: Name: Office of Client Advocacy (OCA) Phone: (918) 295-3101

For concerns about the Notice of Privacy Practices or Privacy Rules:

CMS – Office of Secretary Department of Health and Human Services Washington, D.C. 20201 Toll Free: 877-696-6775

Independence Avenue SW
Room 509 F, HHS Building
Washington, D.C. 20201
OCR Hotlines – Voice: 1-800-368-1019

I acknowledge that the contents of this notice were explained to me by I have read and understand these procedures or will clarify any questions with my clinician.
I acknowledge that the contents of this notice were explained to me on Date* by ILCS staff member Name of person conducting the intake*.
Client (14 or Older) Signature:*

Clear
Date:

MonthDayYear
Date
Parent / Guardian’s Signature:*

Clear
Date:

MonthDayYear
Date
CLICK ON NEXT

Consent for Treatment
Name*

First NameLast Name
Application is hereby made by the undersigned for voluntary admission for services of Improving Lives Counseling Services, Inc., as a voluntary client under the provision of OS43A, Section 9-101 of the OK State Mental Health Law (2006).

I certify that I am eighteen (18) years of age or over. Voluntary admission may be made for any person eighteen (18) years of age or over on his/her own signature. Any person under the age of eighteen (18) years of age may be admitted with the consent of such person and the consent of the person’s parent or guardian, OS43A, Section 5-304.

I have read, or had read to me, the following information about my rights:

A.All persons receiving services from this facility shall retain the rights, benefits, and privileges, guaranteed by the laws and constitutions of the State of Oklahoma and the United States of America, except those specifically lost through due process of law [OS43A, Section 1-103(h)];

B. All persons shall have their rights guaranteed by the Client’s Bill of Rights, unless an exception is specially authorized to these standards or an order of a court of competent jurisdiction;

C. I have been given a summary or full copy of my rights as a client and fully understand the content of this document.

I understand that my treatment records may be subject to review by funding sources and accrediting bodies to verify and evaluate services delivered.

I understand that OS43A, Section 4-201 requires that each client of the agency be charged for care and treatment provided. I have been given a copy of the current rate schedule, and I understand that payment of the charges is adjustable according to my financial ability to pay. An individual will not be refused needed treatment because of the inability to pay: OS, Section 1-202.
Client (14 or Older) Signature:*

Clear
Date:

MonthDayYear
Date
Parent/Guardian Signature:*

Clear
Date:

MonthDayYear
Date
Staff /Witness Signature:

Clear
Date:

MonthDayYear
Date
Consent for Telehealth Treatment

I understand that all existing laws regarding my access to medical information and copies of my medical records apply to telehealth consultation. Additionally, dissemination of any client-identifiable images or information from telehealth interactions to other entities shall not occur without my consent, unless authorized under existing confidentiality laws.

I understand that reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telehealth consultations. All existing confidentiality protections under federal and Oklahoma State law apply to information disclosed during telehealth consultations.

Risks and Consequences

The telehealth consultation will be similar to a routine office visit, except interactive video technology will allow you to communicate with a clincian at a distance. At first you may find it difficult or uncomfortable to communicate using video images. The use of video technology to deliver mental health and educational services is a new technology and may not be equivalent to direct contact.

Rights

You may withhold or withdraw consent to telehealth consultations at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the option to consult with the clinician in person (if it is safe to do so) if you travel to his or her location.
Consent to Telehealth Client (14 or Older) Signature:

Clear
Date

MonthDayYear
Date
Consent to Telehealth Parent/Guardian Signature:

Clear
Date

MonthDayYear
Date
CLICK ON NEXT

Agency Consent Form - Children Only

Not Required to be Filled Out
Name

First NameLast Name
I, (parent/guardian) give my permission for The Agency to Provide
(please initial the appropriate lines)
Transportation as needed

Clear
Therapeutic services on school premises

Clear
for my child
from date

MonthDayYear
to Discharge
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Date
Staff /Witness Signature:

Clear
Date:

MonthDayYear
Date
CLCIK ON NEXT

Participant Orientation Summary
Name*

First NameLast Name
I am voluntarily becoming a registered client of Improving Lives Counseling Services, Inc. I have received a copy of the PARTICIPANT MANUAL for my use and reference.
I AGREE that I can be contacted for future follow-up and outcome evaluation of service.
Yes or No
RIGHTS AND RESPONSIBILITIES:
I have read or have had explained to me my rights and responsibilities as a client.*
Please Initial
I understand these rights and the rules of programs participation.*
Please Initial
I understand my responsibility to give opinions and suggestions and to express any difficulties, complaints or problems I may encounter with or during services. I understand how to make a grievance or complaint, and a recommendation. I will participate in providing input to services.*
Please Initial
SAFETY AND EMERGENCY PREPAREDNESS:
I understand the safe places for emergency shelter, where to go, and what the alarms or signals are. (for in office visits only)*
Please Initial
I understand that I must report any infectious or contagious condition to my counselor as soon as I know of it. This is to protect others and myself. I know what to do if I think I may have been exposed to anything infectious, including TB, and how to report this. I understand that the best protection is not to be exposed and to avoid exposure by avoiding body secretions, including coughs and blood, and to wash thoroughly as a universal protection. (for in office visits only)*
Please Initial
I understand the policies of NO Weapons, NO Threats, NO Violence, and NO Substance Abuse. (for in office visits only)*
Please Initial
I understand that NO tobacco use is permitted at Agency offices. (for in office visits only)*
Please Initial
CONFIDENTIALITY:
I understand that I must give confidentiality to all persons I meet in services. What I learn about others stays here.*
Please Initial
I understand the laws providing me with confidentiality. I understand that confidentiality may be broken if I threaten to harm myself, threaten to harm someone else, if a judge orders that my records be release, if I sue the agency or one of the clinicians, or if I report abuse of a child or other person that is dependent on others for care. I understand the exceptions.*
Please Initial
PHYSICAL CARE:
I understand my counselor and my physician need to consult at times.*
Please Initial
If I am prescribed medications by my physician, I understand that I am not to bring these or over-the-counter (OTC) medications with me to counseling unless pre-arranged with my counselor. If I do bring any medications, I will notify my counselor immediately. I will not share my medications with any other person.*
Please Initial
Client (14 or Older)*

Clear
Date:

MonthDayYear
Date
Parent/Guardian Signature:*

Clear
Date:

MonthDayYear
Date
Staff /Witness Signature:

Clear
Date:

MonthDayYear
Date
I acknowledge that I have received information to access the Participant Orientation and Information Guide. (This information is provided on the last page of the intake)
Client (14 or Older) Signature:*

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature:*

Clear
Date:

MonthDayYear
Date
Staff/Witness Signature:

Clear
Date:

MonthDayYear
Date
CLICK ON NEXT

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

(Not Required. Can be Added Later Also)
Name

First NameLast Name
I, (Name of Client)

First NameLast Name
Date of Birth
authorize Improving Lives Counseling Services, Inc. and its duly authorized agents and employees to
Release to (give information to)
Please Initial
Obtain From (get information from)
Please Initial
The following person or agency:
For the Following Information (specific information requested):
For the Following Purpose (specific need /reason):
This release is only valid from (date):

MonthDayYear
Date
Treatment services are not contingent upon, or influenced by, the client’s decision to or not to permit the release of this information. The client’s consent shall be freely and voluntarily given. The information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but not limited to, diseases such as hepatitis, syphilis, gonorrhea, and AIDS. Psychiatric Records: Oklahoma State Law (76 OS 1986, Section 19) provides that the psychological or psychiatric records may be provided to a patient only if the treating physician/practitioner consents to the release or upon request of a court order, issued by a court of competent jurisdiction. Therefore, The Agency will not release psychological or psychiatric records to patients, their guardians or agents (including attorneys) except with the consent of the treating physician/practitioner or upon the receipt of a court order, issued by a court of competent jurisdiction. Drug/Alcohol Records: Confidentiality of drug/alcohol abuse records is protected by Federal Law. Federal y Regulations (42 CFR Part 2) prohibit you from making further disclosure of this information unless disclosure is expressl permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42CFE Part 2. A

GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMAITON IS NOT SUFFICIENT FOR THIS PURPOSE. The Federal rules restrict the use of the information to criminally investigate or prosecute any alcohol/drug patient.

I understand that my records are protected under the Federal and State Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has be en taken in reliance on it (e.g. probation, parole, etc)

I do not authorize further release to any other party. I do understand that The Agency and its staff, employees, officers, and directors cannot be responsible for the confidentiality disclosed after said information has been released pursuant to this authorization, and hereby, release them from any liability arising from such disclosure. I authorize this consent to release confidential information.
Client (over 18) or Legal Guardian Signature:

Clear
Date:

MonthDayYear
Date
Staff/Witness Signature:

Clear
Date:

MonthDayYear
Date
CLICK ON NEXT

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION MEDICAID/SOONERCARE RELEASE

REQUIRED FOR ALL MEDICAID/SOONERCARE/INSURE OK CLIENTS
Name

First NameLast Name
I, (name of client)
DOB:
authorize Improving Lives Counseling Services, Inc. and its duly authorized agents and employees to
Release to (Required if Medicaid/Soonercare/Insure OK)
Please Initial
Obtain From (Required if Medicaid/Soonercare/Insure OK)
Please Initial
Oklahoma Health Care Authority

For the Following Information (specific information requested):

Information needed for the named person to receive services

For the Following Purpose (specific need /reason):

Collaboration, Verification, and Audits
This release is only valid from (date):

MonthDayYear
Date
Treatment services are not contingent upon, or influenced by, the client’s decision to or not to permit the release of this information. The client’s consent shall be freely and voluntarily given. The information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but not limited to, diseases such as hepatitis, syphilis, gonorrhea, and AIDS. Psychiatric Records: Oklahoma State Law (76 OS 1986, Section 19) provides that the psychological or psychiatric records may be provided to a patient only if the treating physician/practitioner consents to the release or upon request of a court order, issued by a court of competent jurisdiction. Therefore, The Agency will not release psychological or psychiatric records to patients, their guardians or agents (including attorneys) except with the consent of the treating physician/practitioner or upon the receipt of a court order, issued by a court of competent jurisdiction. Drug/Alcohol Records: Confidentiality of drug/alcohol abuse records is protected by Federal Law. Federal Regulations (42 CFR Part 2) prohibit you from making further disclosure of this information unless disclosure is expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42CFE Part 2. A

GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMAITON IS NOT SUFFICIENT FOR THIS PURPOSE. The Federal rules restrict the use of the information to criminally investigate or prosecute any alcohol/drug patient.

I understand that my records are protected under the Federal and State Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

I also understand that I may revoke this consent at any time ex cept to the extent that action has been taken in reliance on it (e.g. probation, parole, etc I do not authorize further release to any other party.

I do understand that The Agency and its staff, employees, officers, and directors cannot be responsible for the confidentiality disclosed after said information has been released pursuant to this authorization, and hereby, release them from any liability arising from such disclosure. I authorize this consent to release confidential information.
Client (18 or older) or Legal Guardian Signature:

Clear
Date:

MonthDayYear
Date
Staff/Witness Signature:

Clear
Date:

MonthDayYear
Date
CLICK ON NEXT

DESIGNATION OF A TREATMENT ADVOCATE - ADULTS ONLY
Name*

First NameLast Name
Date:

MonthDayYear
Date
Each person being served by a licensed mental health provider or organization has the right to name a Treatment Advocate for the following reasons: 1) Someone with whom you would like to partner with during your course of treatment and, 2) Someone you trust and whose advice you value, such as a family member, spouse/partner, friend or representative from an advocacy organization. You have the right to set limits regarding the level of involvement of the person you select and you have the right to change your selection at any time. You also have the right to not name a Treatment Advocate. Should you name a Treatment Advocate, this person must agree to serve and to adhere with all standards of confidentiality.

Treatment Advocate Election (Please select one response)
Please Select

Yes, I wish to name a Treatment Advocate.No, I do not wish to name a Treatment Advocate at this time. However, I may elect to do so at any time in the future.
If you elected to name a Treatment Advocate, please identify that person now.
Name:
Daytime Phone:
Evening Phone:
Mailing Address:
I want my Treatment Advocate to be notified of any change in my level of care.

YesNo
I would like my Treatment Advocate to participate: (select one or more options)

To only be kept informed by meIn treatment evaluations and discharge planningBy following my Psychiatric Advanced DirectiveOther
Treatment Advocate’s Statement of Agreement

Yes, I agree to serve as a Treatment Advocate. I acknowledge that I have received information regarding confidentiality policies and agree to comply with those standards. I understand that the degree of my participation is determined by the person being served and that she/he may indicate changes to and or revoke this agreement at any point.
Client’s Signature*

Clear
Date

MonthDayYear
Date
Treatment Advocate’s Signature

Clear
Date

MonthDayYear
Date
*Verbal confirmation from Treatment Advocate
Received On

MonthDayYear
Date
by Staff Member's Name
Staff Signature

Clear
CLICK ON NEXT

- At Improving Lives Counseling Services we strive to provide excellent service for the clients we serve. If you feel like the services we have provided can be improved or you would like to file a complaint please contact our Administrative Director listed below.
Becca Kay (918)960-7852 Becca@ImprovingLivesCounseling.com
- If you are concerned about safety or quality of care violations please contact the Joint Commission via their website located at www.JointCommission.org
- For a list of your rights as a client of Improving Lives Counseling Services, as well as information about the agency, please reference our Participant Orientation and Information Guide located at https://improvinglivescounseling.com/wp-content/uploads/Participant-Orientation-Guide.pdf
I acknowledge that I have reviewed this information
Client Name:*
Client/Guardian Signature:*

Clear
Make sure you get your clinician's email address before submitting

DO NOT click submit until you have entered your clinician's email address. Enter your clinician's email address in the box below and then CLICK ON SUBMIT.
CLINICIAN EMAIL ADDRESS*
Please ask your clinician for their email address to complete this field
Should be Empty:

Client Demographics

Emergency Contact

CLICK ON NEXT

Participant Rights for Outpatient Services

CLICK ON NEXT

Procedures For Client Grievances and Other Issues

CLICK ON NEXT

Consent for Treatment

CLICK ON NEXT

Agency Consent Form - Children Only

CLCIK ON NEXT

Participant Orientation Summary

CLICK ON NEXT

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

CLICK ON NEXT

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION MEDICAID/SOONERCARE RELEASE

CLICK ON NEXT

Suicide Risk Assessment

CLICK ON NEXT

DESIGNATION OF A TREATMENT ADVOCATE - ADULTS ONLY

CLICK ON NEXT

Adverse Childhood Experience (ACE) Questionnaire

CLICK ON NEXT

Make sure you get your clinician's email address before submitting