Download Family Willows Substance Use Treatment Center Intensive

Family Willows Substance Use
Treatment Center
161 South Beech Street, Manchester NH 03103
603.641.9441
Intensive Outpatient Program &
Outpatient
Informed Consent
Welcome to the Family Willows
The Family Willows is committed to treating the family or individual as a system. We believe everyone
deserves integrated, individualized and the highest quality of treatment, discharge and aftercare to meet
the complex needs of substance use and mental health disorders. The Family Willows believe each person
who walks through our doors should have access to the services they need despite the ability to pay. The
Family Willows staff will work with you to reduce and eliminate substance use and harmful behaviors in
your life by building skills that will allow you to be more independent and self-sufficient.
By entering into the Family Willows Substance Use Treatment Program you are becoming a participant in
a program which means you are agreeing to work closely with your assigned treatment team You agree
to work closely with your treatment team on creating an individualized treatment plan unique to your
needs. Treatment includes intensive group work, individual therapy, case management, recovery
supports, trauma and addiction psycho-education as well as family group therapy. Participants will be
individually assessed regularly throughout treatment for readiness for completion or discharge and to
ensure effective and appropriate treatment.
The Family Willows consist of two different levels of treatment. The first level of treatment is an Intensive
Outpatient Program and the second level of treatment is our Outpatient Program. In total our program
can last up to 16 weeks.
You will have many opportunities to learn and discuss the core principles of treatment during the course
of your programming. Please ask your treatment team to explain anything you do not understand or
answer any questions you may have.
Family Willows Staff
All Staff of the Family Willows Program adhere to the highest professional and ethical standards set forth
by the New Hampshire Bureau of Drug and Alcohol Services. Many of the staff are licensed in the State of
New Hampshire and follow their respective code of ethics. All of these standards and code of ethics are
available for you to review upon request. Below is the staff of the Family Willows treatment team:
Meghan Shea, LICSW, MLADC, Clinical Director
Karen Frarie, LICSW, MLADC, Program Manager
Elizabeth (Liz) Vicente, LICSW, MLADC-Therapist
Lisa Jobin, LCMHC – Therapist
Katie Laux, MLADC - Therapist
Melissa LaPlace, BA, LADC- Intake Coordinator
Melissa Newman BSW- Treatment Coordinator
Michelle Bruce, CRSW – Recovery Support Worker
Jennifer Mellor, Recovery Support Worker
Paloma Cassina- Medical Biller
Consultation and Supervision:
Each treatment provider at the Family Willows Substance Use Treatment program participates in regular
clinical supervision and peer case consultation with clinicians who are bound by the same standards of
confidentiality. Staff members must engage in this practice to maintain their licensure in the state of New
Hampshire. The goal of this supervision and consultation is to provide the most effective and helpful
services to our clients and to continually improve our skills as clinicians. As part of this supervision and
consultation, your counselor may request your permission to audio or videotape sessions with you. We
assure you that these tapes will be used only for quality assurance and supervisory purposes. Tapes will
be erased after being reviewed. If you do not want your sessions to be taped (in whole or part), you are
under no obligation to consent to this request and your eligibility for services will not be affected.
What to Expect from Treatment
Your treatment is a process in which you will work with your treatment team in order to resolve
problems and meet agreed upon goals. Group and individual therapy is not like a visit to a medical
doctor. Rather, it calls for a very active effort on your part. In order for your treatment to be most
successful, you will have to work on things that are discussed both during sessions and at home.
Treatment can have risks and benefits. Group and individual therapy often involves discussing
unpleasant aspects of your life and you may experience uncomfortable feelings as a result. However, the
treatment process has also been shown to help individuals resolve specific problems and reduce feelings
of distress.
Your Rights
As a client of the Family Willows Substance Use Treatment Center, you have several rights. The following
is a list of rights you have as a client of the program.
You have the right to:
 Decide not to enter any level of treatment services that is provided at FIT.
 Decide to terminate services at any time.
 A safe environment, free from emotional, physical, and sexual abuse.
 Be treated with respect by self, staff, and other clients.
 Be free from discrimination from self, staff, and other clients, including but not limited to
racial, color, sexual orientation, national origin, disability, religious, age, gender, or economic
discrimination.
 Complete and accurate information about your treatment including goals, methods, potential
risks and benefits, and progress.
 Information about the professional capabilities and limitations of any professional involved in
your treatment.
 Receive treatment from trained and qualified professionals.
 Written information about fees, payment methods, and lengths and duration of sessions and
treatment.
 Be informed about the limits of confidentiality, the situations in which your counselor and/or
the agency is legally bound to disclose information to outside persons or agencies, and the
types of information that will be disclosed.
 Know if your counselor will discuss your case with supervisors or peers.
 Request a summary of your treatment.
 Request the release of your clinical information to any agency or person that you choose.
 Be referred to appropriate community services, based on individual needs, as we are able to
identify them.
 If you are asked to leave the program, to know why you are being asked to leave and what
conditions you must meet in order to return to Families in Transition, Family Willows
Treatment Center.
 File a grievance with Families in Transition if you feel that any of your rights have been
violated.
Confidentiality
The confidentiality of client records maintained by Families in Transition is protected by federal law and
regulations. Generally, we may not say to a person outside of this agency that a client receives services
here, or disclose any information identifying a client as a person misusing alcohol or other drugs. The
exceptions to this include (a) with written consent from you, (b) if the disclosure is permitted by court
order, (c) the disclosure is made to medical personnel in a medical emergency, or (d) to report suspected
child abuse and neglect or suspected elder or incapacitated adult abuse, neglect, or exploitation. In
addition, the New Hampshire Department of Health and Human Services Bureau of Community Health
Services is authorized to review our records to ensure that we are providing quality services.
Violation of the federal law and regulations by this agency is a crime. Suspected violations may be
reported to appropriate authorities in accordance with federal guidelines. Federal law and regulations do
not protect any information about a crime committed by a client either on Families in Transition
property, against any person who works for Families in Transition, or any threat to commit such a crime.
(See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for federal laws and 42 CFR part 2 for federal regulations)
Unlike individual treatment, confidentiality of group therapy is not protected by law. Group members
must sign and abide by a written confidentiality agreement prior to participating in group. Clients with
concerns about confidentiality should discuss them prior to beginning treatment.
Appointments/Cancelation Fee
Individual sessions are normally 50-60 minutes and are scheduled weekly throughout your treatment
with both your individual therapist and treatment coordinator. Group sessions are 1-3 hours long
depending on the group. We ask that you be on time for all appointments and group sessions. If you
need to cancel or reschedule an appointment, please contact your counselor as soon as possible. If you do
not show up for three (3) sessions in a row, individual or group session your treatment provider may
terminate services. We will bill you for missed appointments that have not been canceled at least 24
hours in advance. This missed session fee is $ 5.00.
Insurance/Managed Care and Payment
The Family Willows Substance Use Treatment Center is an in-network provider for a select number of
insurance companies. It is important to note that using third party payers, such as insurance companies,
carry a certain amount of risk in regards to confidentiality. Therefore, our affiliation with insurance
companies is minimal. If you choose to use your health insurance to pay for treatment, be aware that your
insurance company may have access to information about your mental health. Therapists are required to
provide information so that individuals may receive benefits, and this typically involves making a
diagnosis from the DSM- 5 (Diagnostic and Statistical Manual of Mental Disorders), the utilization of the
American Society of Addiction Medicine (ASAM) and giving relevant treatment information. Additionally,
utilizing insurance companies may limit the length of appointments and overall services. Many health
care plans offer out-of-network benefits, in which you still may be eligible for reimbursement of services.
In the event that you request that we bill your insurer, you give authorization to Family Willows to release and
exchange confidential information about your treatment and family history to your insurance company or third
party payer in order for services to be provided and reimbursed. The balance of treatment costs will be
charged to you based on income guidelines. At intake, staff will inform you of your portion of fees per
session. Payment of fees for services are expected on the day that services are delivered and any balance
must be paid in full prior to receiving additional services unless special arrangements are agreed upon
with your treatment provider. You may stop treatment at any time; however, you will still be responsible
for paying for services you have already received.
Group Schedule
Morning Intensive Outpatient Program:
 Phase 1 – Monday, Wednesday, and Friday 9am – 12pm*
 Phase 2 – Tuesdays & Thursdays 9am – 12pm*
Afternoon Intensive Outpatient Program:
 Phase 1: Monday, Wednesday and Friday 2pm- 5pm*
 Phase 2: Tuesday & Thursday 2pm- 5pm*
Additional Outpatient Groups:
 Nurturing Families Group
 Wellness Group
 Family/Supportive Person Session*
***Required for completion of treatment
Phase Transitions & Graduation
Movement from Phase 1 to Phase 2 will be decided based on completion of program goals and personal goals.
When you believe you have completed your goals, you will be asked to submit a request to transition, which
you will present to the group for discussion and feedback. Upon the group’s and staff’s approval, you will
move to the next phase of your recovery. Graduation from the Intensive Outpatient Program is a great
accomplishment. It is important that you are discussing your recovery/aftercare plan with the group and in your
one on one sessions throughout your treatment.
Attendance
Phase I Attendance Policy: Clients who miss three consecutive group sessions could jeopardize their
treatment services. Clients must provide documentation to their provider or can potentially be
discharged from treatment.
Phase II Attendance Policy: Clients must show commitment towards their recovery, therefor the
attendance policy is reduced to missing 2 group sessions will jeopardize treatment.
Calling Out
Please call 603-641-9441 extension 405 to call out. All callouts must be 2 hours prior to your start
time of treatment. It is extremely important that you are calling out so you do not incur a cancelation fee.
Holiday/Weather Cancelations
The Family Willows will decide the mornings of a snow storm whether group or transportation is in session or
canceled for the day. If group or transportation is canceled it will be indicated on the call out line listed above.
All participants are responsible to call and check the status of the program for that day. There may be
times where transportation is not available but group will be in session. It is then participants’
responsibility to get to the group on their own. If group is canceled for the day all participants are
scheduled to show up the next business day for a make-up group session. If there is a holiday and the
agency is closed, all participants are expected to show up the next business day for a make-up the group
session. Reminder if group is canceled this does not mean the Recovery Center is closed. Staff may still
available for one on one session unless you are contacted otherwise.
Transportation & Childcare
Transportation is an exceptionally limited resource. Thus, we must maintain several strict rules.
o The driver will only wait 2 minutes for you. If you are not out waiting for us or do not
come out quickly, we will leave and it will count as a no show for transportation.
o You must cancel transportation by 2 hours prior to the group start time or earlier. It is
assumed if you do not call staff will be picking your up. If you no call or no show
transportation you are at risk of losing this resource.
o If you do not show for transportation twice, you will lose transportation services.
o The same level of respect must be shown for transportation services as for all other
Families in Transition services, inappropriate behavior will result in loss of services.
Childcare is provided free of charge while you are accessing group treatment.
o Childcare will open for drop-off 10 minutes prior to group starting. Please have your
child dropped off prior to the start of group so that the transition happens as smooth as
possible.
o Staff request that mothers limit disruption to child care room by not visiting during
breaks.
If you no show child care or transportation a warning letter will be sent. One more no show of child care
or transportation after a warning letter has been received will lead to termination of either of these
services.
Drug Testing
Throughout your participation in treatment, you will be required to participate in drug and alcohol
testing. You will be tested on a random basis, during group sessions, individual counseling and case
management sessions. Testing includes urine screens as well as a breathalyzer. All urine screens will be
observed when providing a sample to ensure that there is no tampering with the sample. Drug test
results will be discussed at the time of the drug test. It is important to do this so that this tool is focused
on supporting your treatment and recovery journey, versus punishment. All drug screen results can be
discussed in the group process.
If you are unable or unwilling to provide a urine sample your records will reflect a positive test as a
result. Please be patient, cooperative and respectful when working with the staff. Disrespectful or abusive
behavior will not be tolerated and may result in discharge from treatment. If you encounter any concerns
when working with staff, you should speak to your therapist about the issue.
Observation
The Family Willows is a teaching facility that provides hands on training and diverse learning
experiences to students and/or staff who are pursuing their education in the behavioral health
profession. One tool the Family Willows utilizes to help enhance the learning experience is audio
listening device and the one way mirror in the group rooms. At times during group sessions there may be
staff and interns who are listening and observing the group process for educational and training
purposes only.
Treatment Records
The laws and standards of professional counseling mandate that we keep records of your treatment. You
have the right to receive a copy of your record, or we can prepare a summary of your treatment for you
instead. Due to the professional nature of these records, they can be misinterpreted and/or upsetting to
untrained readers. If you wish to see your records, we recommend that you arrange to do so in the
presence of your primary therapist so that the contents can be discussed. We reserve the right to
withhold the release of your records to outside agencies if you have an outstanding balance.
Family Willows Substance Use Treatment Center Group Rules
 Confidentiality. What is said in the group stays in the group.
 Chance meetings. If chance brings you or another group member into onetime
or regular contact with another participant outside of the group, it’s best not to
acknowledge each other until you’ve had a chance to speak about it in the next
group session and have agreed on whether conversation is acceptable.
 Punctuality. Groups should begin and end on time, to respect other people’s time boundaries. It
can be disconcerting and distracting when one group member is
sharing information and another walks in late.
 Respect. Members can show respect for each other by listening fully when others
speak and refraining from comments unless the speaker requests comments. Furthermore,
members can show respect for each other by silencing or shutting off their cell phone during
groups.
 Food. Members may enjoy a healthy snack and beverage during meetings. Please be mindful of
distractions to the group process while eating to avoid sending a message that they aren’t fully
attending to the other participants.
 Right to be silent. Sometimes there will be group exercises in which people
share information. If a group member is uncomfortable sharing during such an
exercise, he or she may simply say, “I pass.”
 Sharing. The group time is everyone’s time. Don’t dominate the discussion. Listen
ten times as much as you speak.
 Withholding judgment. Practice staying out of judgment by working on listening
skills, refraining from giving advice, learning to be comfortable with silence, using “Istatements” and reaching out with empathy.

Safety: Is the core concept of treatment here at the Family Willows. In order to maintain the
safety of all participants no alcohol or drugs are allowed on the property. Weapons of any kind are
not permitted on the premises. If you are required to take prescribed medications during group
hours you must show proof of the prescription and provide a doctor’s note.
Honesty and Communication
The Family Willows Substance Use Treatment Center believes it is important you are open and honest
with your providers and peers at all times. Treatment cannot be effective unless your team understands
what is going on with you. If we are aware of what you are experiencing then we can work with you on
how to reduce the barriers you may face in your recovery.
We strongly encourage you to reach out to your team for support if you feel an urge to use substances. If
you use do drugs or alcohol, we expect you to reach out and notify your therapist or Case Manager. This
may mean that you report your substance use in group, therapy and/or case management. When
participants wait longer to admit use, they place themselves at risk for continued relapse.
Contingency Management
The Family Willows staff is dedicated to your treatment and hopes that you are as well. We offer weekly
incentives for those participants in Phase I that are working on their recovery. Each participant that
made it to each group session on time and stayed for the entire group will receive a ticket. Participants
also receive a ticket for each individual therapy and case management session. It is the participants’
responsibility to write their name on the ticket and place it in the jar for a chance to participate in the
weekly drawing. At the end of each week there will be a name chosen to claim their personal incentive.
You must be present to win!
Emergency Procedure
It is extremely important to reach out for help in an emergency. At any time you feel that you are
experiencing symptoms of your trauma or addiction such as severe anxiety or depression, you feel you
may hurt yourself or someone else immediately call 911.
Final Thoughts
The Family Willows Substance Use Treatment Center hopes to provide you with a strong foundation to
lead you into a life of recovery. We believe in every person who walks through out doors and it is our
hope you will continue to believe in yourself throughout this journey.
Signed Consent for Treatment: Please read the following statement and indicate your agreement by
signing below.
“I have read and/or had explained all of the preceding statements and understand my rights
and responsibilities for the services rendered by Families in Transition. I agree to these
conditions of my counseling as provided in this agreement.”
___________________________________________
______________________
___________________________________________
Intake Coordinator Signature
______________________
Date
Client Signature
Date
Notice of Privacy Practices
What is this notice?
This notice was prepared to provide you with an understandable explanation about how we may "use"
and "disclose" your "protected health information." Health information is an indispensable part of
healthcare treatment, payment and operations; without access to health information, the healthcare
system cannot function. A Federal Law called the Health Insurance Portability and Accountability Act
(HIPAA), or the Privacy Rule, was created to support your privacy and rights surrounding your health
information.
We understand that health information about you is very personal. Families in Transition is committed to
insuring the privacy and confidentiality of your personally identifiable health information. All employees
and volunteers must sign a confidentiality agreement when hired.
An informed client is an important ally for us in meeting these goals. We hope you will take the time to
read our notice and to call us if you have any questions.
Some useful definitions
Protected Health Information ("PHI") - Any information, created by us in any form that identifies and is
related to the past, present, or future:
1) Physical or mental health of the individual;
2) Provision of health care to the individual; or
3) Payment for health care provided to the individual.
If all personal identifiers have been removed from the information, it is considered "de-identified health
information" and may be used more freely than protected health information.
"Uses" and "Disclosures" - We use these terms as they are defined in the Privacy Rule. We "use" your
protected health information when we examine, review, analyze, or share it within Families in Transition,
Inc. We "disclose" your protected health information when we release, transfer, provide access to, or
share it in any other way with any other organization or individual, for example to a state agency or to a
referring provider.
How do we use and disclose your protected health information?
The Privacy Rule permits us to use and disclose your "protected health information" (PHI) for treatment,
payment, and healthcare operations. Federal regulations governing Confidentiality of Alcohol and Drug
Abuse Patient Records, 42 CFR Part 2, require that we ask for your written consent to disclose your
“protected health information.” The following describes in general how we may use or disclose your
health information for treatment, payment, and health care operations:
Treatment: We may use or disclose your health information to provide and coordinate your treatment.
Families in Transition may use or disclose your health information among members of your treatment
team or other personnel within Families in Transition. If healthcare providers outside of Families in
Transition request your health information, we will ask you for your written consent before sharing the
information.
Payment: We may use and disclose health information about you so that the services you received from
us may be billed for and payment collected.
Health Care Operations: We may use and disclose health information about you within Families in
Transition to make sure that you receive quality care. For example, we may use health information to
review our services, to evaluate the performance of our staff, or to review your records if you file a
complaint.
What other ways may we use and disclose your health information?
Public Health Information (these are required by law): We may use or disclose your health information
when necessary to prevent a serious threat to your health or safety or to the health or safety of others.
For example, health information may be used or disclosed for an Involuntary Emergency Admission or to
report abuse or neglect of minors, elders, or dependent adults.
Health Oversight Activities: We may disclose health information to a health oversight agency for them to
make sure we are following the law. (Audits, inspections, investigations, or licensure)
Emergency Situations: If an emergency happens to you, we may need to release your health information,
without your consent, to medical personnel so they can treat you.
As Required by Law: We may disclose health information about you in situations not already mentioned
when required to do so by federal, state, or local law.
Research: We may disclose your health information to researchers when you have agreed to participate in
a study.
Law Enforcement Activities: We may disclose health information to a law enforcement official for law
enforcement purposes when the information is needed to identify or locate a suspect, fugitive, material
witness, or missing person; to report a death that may be the result of criminal conduct; to report
criminal conduct occurring on our premises; if we receive a court order or subpoena to produce your
health information; if a medical examiner requests your health information; or to the State or District
Attorney’s Office if you are the victim of a crime. Such releases of information will only be made after
reasonable efforts to contact you for your authorization. If we cannot contact you, we will obtain legal
advice, but we may be required to release your records.
What are your privacy rights?
The Federal Privacy Rule gives you several new rights with respect to your protected health information
(in addition to those rights you already have under state law). Beginning April 14, 2003, you have the
following rights to your health information:
 Right to a Paper Copy of this Notice: You have the right to receive written notice of our privacy
practices (That's this document.) If you have received this notice electronically, you have the right
to a paper copy if you want it.
 Right to Request Restrictions: You have the right to ask for further restrictions on the ways in
which we use and disclose your protected health information. We are not required to agree to a
requested restriction. We will not agree to any request unless we feel that we can fully meet our
commitment.
 Right to Request Confidential Communications: You have the right to ask that we communicate with
you in a certain manner or at a certain location. We will make efforts to accommodate reasonable
requests. You must make this request in writing.




Right to Inspect and to Copy: You have the right to see and get a copy of your treatment record or
any other protected health information that we keep in a regular paper or electronic file. We may
charge you a reasonable fee for copies, consistent with state law. You must make this request in
writing. We may ask for a verification of identity as you make these requests. (Note: There are a
few situations specified in the Privacy Rule where this right does not apply.)
Right to Request an Amendment: You have the right to ask for an amendment of your protected
health information. Entries are not deleted from medical records because of legal requirements
but may be corrected or amended by the author of the entry. You may request an amendment of
your treatment record or other protected health information that we keep in a regular file. You
must make this request in writing. If the information is accurate and complete as determined by
the author of the entry, we will decline the request for amendment but will include your request
and statement of disagreement in your file.
Right to Request a List of How We Shared Your Health Information: You have the right to receive a
written accounting of the disclosures we have made of your protected health information. This
accounting does not include disclosures for treatment, payment or healthcare operations,
disclosures authorized by you, and certain other exceptions. You must make this request in
writing.
Right to Designate a “Personal Representative:” You have the right to designate a "Personal
Representative" to help you exercise your rights concerning your protected health information.
This personal representative must be designated in writing, and must show this designation any
time he or she wishes to exercise the rights attached to it. New Hampshire State laws apply to the
rights and responsibilities of personal representatives.
Our Duties to You
We are required by law to maintain the privacy of your personal health information, and to give you
notice of our legal duties and privacy practices with respect to your protected health information.
We are required to abide by the terms of our Privacy Notice currently in effect.
We reserve the right to change our privacy practices (that is, to change the ways in which we use or share
your protected health information as described in the Notice), so long as the new practices are permitted
by the Federal Privacy Rule or other applicable law, and are described in a revised Notice of our privacy
practices.
We further reserve the right to make any such revised Notice provisions effective for all protected health
information we maintain, including information created or received before the effective date of the
revised Notice.
Questions or Complaints?
If you have a question or believe your privacy rights have been violated, you may request clarification or
file a complaint with us or with the Bureau of Drug and Alcohol Services of NH. Families in Transition’s
Privacy Officer will assist you with your complaint, if you request such assistance.
Meghan Shea, Clinical Director
Families in Transition
122 Market Street
Manchester NH 03101
Phone: (603) 641-9441
Stephanie Savard, COO
Families in Transition
122 Market Street
Manchester, NH 03101
Phone: (603) 641-9441
New Hampshire Department of Health and Human Services
Attn: Bureau of Drug and Alcohol Services
105 Pleasant Street Main 3rd Floor North
Concord NH 03301
(603) 271-6738
All complains must be submitted in writing. We will respond to all properly filed complaints. You will
not be adversely affected or discriminated against in any way for filing any such complaint.
NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT
I have received a copy of the Families in Transition Notice of Privacy Practices. I understand that Families
in Transition has the right to change its Notice of Privacy Practices from time to time and that I may
contact Families in Transition at any time to obtain a current copy of the Notice of Privacy Practices.
______________________________________________________
Client Name (Print)
______________________________________________________
Signature of Client/Legal Representative
____________________________________________________
Relationship to Client
______________________________
Date
FOR OFFICE USE ONLY
PRINT PLEASE
I have attempted to obtain the patient’s signature on this form, but was not able to for the
following reason: _________________________________________________________________________
Please document the reasons you were unable to obtain the signature.
Date:
Initials: