Download MFH Intake Form - My Friend`s House

371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
PHONE
856-384-0366
FAX
6+
Appointment Date:
Appointment Time:
NOTE: Kindly attach all assessments, evaluations, court orders and authorization forms with this referral.
Client’s Name:
DOB:
SSN#:
Age:
SBI#:
Medicaid#:
Address:
Phone#:
Referred by:
MARITAL STATUS:
Phone #:
☐ Married
☐ Single
Fax#:
☐ Divorced
☐ Widowed
☐ Domestic Partner
REASON FOR REFERRAL:
SERVICES[S] OR PROGRAM[S] REQUESTED
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Drug/Psych Evaluation
Individual/Family Counseling
Group Counseling
Case Management
Psychiatric Evaluation
Medication Monitoring
IOP / OP / Substance Abuse Treatment
Co-Occurring
Anger Management/DV/Parenting
SOP
FOR OFFICE USE ONLY (PAYER SOURCE)
☐ Medicaid
☐ SPB/Probation
☐ SAI
☐ County
☐ DUII
☐ SJI
☐ Drug Court
☐ Self
NOTE: PLEASE INFORM CLIENT THAT ALL INSURANCE CARDS AND id MUST BE BROUGHT TO THE INITIAL INTAKE APPOINTMENT.
PLEASE FAX THIS REFERRAL TO 856-384-0366. IF CLIENT IS COVERED BY COMMERCIAL INSURANCE, PLEASE COMPLETE INSURANCE
VERIFICATION FRORM AND FAX TO 609-365-2761.
Please fax referrals to 856-384-0366
INSURANCE VERIFICATION
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
PATIENT INFORMATION
Patient’s Name:______________________________________________________DOB:___________________________
SSN:________________________________Address:_______________________________________________________
Phone#:_____________________________City/State/Zip:__________________________________________________
Employer:__________________________________________________________________________________________
SUBSCRIBER INFORMATION
Insured’s Name:______________________________________________Relationship:____________________________
SSN:_____________________________DOB:__________________________Phone:_____________________________
Address:___________________________________________________________________________________________
Employer:__________________________________________________________________________________________
PRIMARY INSURANCE INFORMATION
Insurance Carrier:____________________________________________________________________________________
Policy/ID#:_______________________________________________Group #:___________________________________
Insurance Phone (Mental Health Line):___________________________________________________________________
SECONDARY INSURANCE INFORMATION
Insurance Carrier:____________________________________________________________________________________
Policy/ID#:_______________________________________________Group #:___________________________________
Insurance Phone (Mental Health Line):
___________________________________________________________________
NOTE: PLEASE INFORM CLIENT THAT ALL INSURANCE CARDS AND id MUST BE BROUGHT TO THE INITIAL INTAKE APPOINTMENT.
PLEASE FAX THIS REFERRAL TO 856-384-0366. IF CLIENT IS COVERED BY COMMERCIAL INSURANCE, PLEASE COMPLETE INSURANCE
VERIFICATION FRORM AND FAX TO 609-365-2761.
Please fax referrals to 856-384-0366
Intake Sheet
Page 2 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Name:
Birth Date:
Address:
Intake Date:
City:
Phone (Home/Cell):
State:
Phone (Work / Bus):
Zip Code:
SSN
Employer Name:
Address:
City:
State:
Zip Code:
RELATIONSHIP STATUS
☐ Married
☐ Never Married
☐ Separated
☐ Committed Relationship
☐ Divorced
☐ Widowed
CHILDREN: (Name)
1.
CHILDREN (Age)
Age
2.
Age
3.
Age
4.
Age
5.
Age
EMPLOYER/SCHOOL
Address:
City:
State:
Zip Code:
Occupation:
Length of current employment:
/
Yrs.
Funding sources identified at time of intake:
Self
SJI
Drug Court
☐
☐
☐
Emergency Contact Info:
Name:
WFNJ/SAI
☐
NJAI
☐
DUII
☐
DYFS
☐
Mos.
DAS County
☐
Relationship:
Address:
Phone:
City:
Employer:
State:
Current reason for seeking treatment:
☐ Alcohol or Drugs
☐ Social / Emotional
☐ Academic / Career
☐ Court Ordered
☐ Psychiatric
☐ Referred
☐ Other
Zip Code:
Referred by?
Have you been in treatment before:
☐ Yes ☐ No
If yes, where and when?
Are you taking any prescribed medications? ☐ Yes ☐ No
Medications:
1.
2.
3.
Page 3 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
4.
Are you presently in a crisis situation or in need of medical
or psychological attention? ☐ Yes ☐ No
Explain:
Reason for meds?
Legal Status: (Check all that apply)
☐ No Legal Problem
☐ Parole / Date Ends
☐ Probation / Date Ends
☐ IDRC
☐ Criminal Case Pending
☐ Other
☐ Drug Court
☐ DYFS
☐ Family Court
Blackouts (gaps in memory): ☐ Yes ☐ No
If yes, approximately how many times? [enter #] times
Describe most recent blackout experience (if applicable):
Repeated falls, fights, work/sports injuries, etc.: ☐ Yes ☐ No
Describe most recent occurrence (if applicable):
If yes, approximately how many times? [enter #] times
Any hospitalizations for medical or mental health? ☐ Yes ☐ No
If yes, where and when?
Negative changes in social circle/recreational activities? ☐ Yes ☐ No
If yes, describe:
Relationship problems / Domestic violence?
☐ Yes ☐ No
Frequent Job changes
☐ Yes ☐ No
Frequent geological moves
☐ Yes ☐ No
Frequent minor legal infractions
☐ Yes ☐ No
Family history of substance abuse problems
☐ Yes ☐ No (if yes, describe)
Financial difficulties ☐ Yes ☐ No
Brief Explanation:
Drug History
Page 4 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Have you used any drugs or alcohol within the last six months ☐ Yes ☐ No
Date of last
use
a. ☐ Alcohol
b. ☐ Heroin
c. ☐ Methadone
d. ☐ Other Opiates
e. ☐ Cocaine / Crack
f. ☐ Marijuana
/
/
/
/
/
/
/
/
/
/
/
/
Date of last
use
g. ☐ Meth
h. ☐ Amphetamines
i. ☐ Stimulants
j. ☐ Benzodiazepines
k. ☐ Other Tranquilizers
l. ☐ Barbiturate
Do you smoke tobacco? ☐ Yes ☐ No
/
/
/
/
/
/
/
/
/
/
/
/
Date of last
use
m.
n.
o.
p.
q.
r.
☐ PCP
☐ Hallucinogens
☐ Inhalants
☐ Over the Counter
☐ Other Sedatives
☐ Other
/
/
/
/
/
/
/
/
/
/
/
/
How many per day?
Primary Drug of Choice
Secondary Drug of Choice
Drug[s] Codes Above
Route of Administration
Frequency
Age at First Use
Route Codes
1.
2.
3.
4.
5.
Oral
Smoking
Inhalation
Intramuscular
Intravenous
1.
2.
3.
4.
5.
6.
Frequency Codes
Not used in past month
Less than weekly
1-2 times per week
3-4 times per week
Daily
2 or more times per day
Assessors / Counselor Name/Title
Date:
/
/
Signature
Date:
/
/
Client’s Name (Please Print):
Date:
/
/
Signature
Date:
/
/
Page 5 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Presenting Problem
List the problems you want to work on while in treatment. Please identify each one and note the length of time these
problems have existed.
Briefly describe your reasons for seeking treatment at this time.
What has been your feeling about the results of past treatment experiences (if any)? What should be different this time?
Check all specific problems applicable to you:
☐ Sleep Disturbance
☐ Impaired Memory
☐ Depression, Moodiness
☐ Speech Disturbance
☐ Truancy, Runaway
☐ Social Withdrawal, Isolation
☐ Feeling of Persecution
☐ Anxiety
☐ Excessive Fears
☐ Anger
☐ Bothersome Thoughts
☐ Hallucinations
☐ Crying Frequently
☐ Family Problems
☐ Use or Possession of a Weapon
☐ Child Abuse
☐ Seizures, Convulsions
☐ Inferiority Feelings
☐ Suicidal Thoughts
☐ Hyperactivity, Agitation
☐ Violent Fights
☐ Physical Problems
☐ Homicidal Thoughts
☐ Eating Disturbances
What do you perceive your current strengths and weaknesses to be?
What impact has drugs and/or alcohol had on your life? That is, how have drugs and/or alcohol changed your life or lifestyle?
What situations or issues would make you think about leaving treatment?
Page 6 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Financial Assistance Application
Client Name
Date:
/
/
My Friend’s House is a partially funded non-profit organization. Our funding sources vary, and we try to assist those clients with
financial hardships to attain the best help available. The following documentations is needed to assist us in helping you. Available
funds are always in short supply. Please do not apply for assistance if you are financially able to pay your own way.
All of the following need documented proof
INCOME
Annual household Income:
Documentation: Pay stub, tax form from prior year, notarized letter from employer
Additional Income:
Documentation: Child support, SSI, Disability, etc.
Please note: If the income is 250 % of poverty or below you do not need documentation below.
EXPENSE
Mortgage/Rent
Fines/Surcharges
Fines/Surcharges
Electric
Water
Gas
Credit Card
Groceries
Loans
Head of Household ☐
Spouse ☐
I
Signature
Homeowners Insurance
Property Tax
Phone
Sewer
Car Payment
Car Insurance
Car Fuel
Legal Fees
# of Children
attest the above information and documentations is true.
Date:
/
/
Assessors / Counselor Name/Title
Date:
/
/
Signature
Date:
/
/
Page 7 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Agreement of Treatment
Disclosure Regarding Provision of Counseling Services
Client Name
In accordance with the New Jersey Office of Attorney General Division of Consumer Affairs State board of Marriage and Family
Therapy Examiners Alcohol and Drug Counselor Committee (hereinafter referred to as “The State licensing body” Statues and
Regulations, My Friend’s House has advised me of the following:
In accordance with Regulation 13:34C-3.2(c), I understand that I may receive counseling services from a staff member who is not a
(Licensed) Certified Alcohol and Drug Counselor (L) CADC; however, this individual shall remain under the clinical supervisor of an
appropriately licensed certified supervisor as per Regulation 12:34C-6.2(c).
I have been informed that I may be counseled by either a counselor intern or a certified alcohol and drug counselor and requires
supervision in order to provide counseling.
I also understand that
, LCADC, is the clinical supervisor for my treatment and has
access to my treatment record. I understand that the supervisor is ultimately responsible for all aspects of my treatment.
Signature of Client:
Date:
/
/
Client Name
Counselor Name/Title
Date:
/
/
Signature
Date:
/
/
Clinical Director’s Name/Title
Date:
/
/
Signature
Date:
/
/
Original copy of this form will be placed in Client Medical Records file.
Page 8 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Confidential Brief Health Information Form
Name:
Birth Date:
Address:
Phone (Home/Cell):
City:
SSN:
/
/
State:
Zip Code:
Primary Care Physician
Today’s Date
/
/
Month and year of last physical
/
/
Allergic to any medication ☐ Yes ☐ No
If allergic to meds, please specify:
Presently receiving medical attention? ☐ Yes ☐ No
Possible concerned about any medical condition not yet examined by a physician? ☐ Yes ☐ No
If Yes, please specify:
Please check any of the following for which you have received care or currently have:
☐ Allergies
☐ Asthma
☐ Breathing problems
☐ Emotional problems
☐ Vision problems
☐ Thyroid problems
☐ Heart murmur
☐ Intravenously Drugs
☐ Headaches
☐ Hepatitis
☐ Chronic pain
☐ Arthritis
☐ Stomach problems
☐ Blood pressure
☐ Tuberculosis
☐ Heart disease
☐ Diabetes
☐ Epilepsy / Seizures
☐ Hearing difficulty
☐ Cancer
☐ Head injury
☐ Rheumatic Fever
Please list any hospitalizations (Dates and reasons)
1. [
]
2. [
]
3. [
]
Reasons:
Currently under the care of a physician? ☐ Yes ☐ No
If so, when?
/
/
Please list any prior mental health services received:
1. [
]
2. [
]
3. [
]
Please list any medications presently prescribed (medication name, dosage, how often)
List medications
ex. 25mg:
ex. 2 x daily:
1. [
]
[
]
[
2. [
]
[
]
[
3. [
]
[
]
[
4. [
]
[
]
[
5. [
]
[
]
[
6. [
]
[
]
[
]
]
]
]
]
]
Page 9 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
☐ Yes ☐ No
Specify quantity and frequency:
Do you consume alcohol? ☐ Yes ☐ No
Specify quantity and frequency:
Do you smoke tobacco?
Please describe any medical concerns not listed above that you believe relevant:
Counselor Intern’s Name/Title
Signature
Date:
/
/
Client’s
Date:
/
/
Signature
Date:
/
/
Page 10 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
HIV / AIDS Consent Verification
I,
acknowledge the following:
(Print Name)
☐ I accepted referral for HIV/AIDS counseling and/or testing as this agency does not test for HIV/AIDS at this time.
☐ I do not accepted referral for HIV/AIDS counseling and/or testing.
 If you check the “I do not accept referral” box, you don’t have to complete the following (HIV/AIDS Screening
Tool) page.
Client’s Name (Please Print)
Signature
Date:
/
/
Counselor Intern’s Name/Title
Date:
/
/
Signature
Date:
/
/
Page 11 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
HIV / AIDS Screening Tool
Since 1990 have you ever:
1. Had unprotected sex, oral, or anal sexual activity or intercourse?
☐ Yes ☐ No
2. Had unprotected sex with a man who has had sex with another man or other men?
☐ Yes ☐ No
3. Had unprotected sex with someone who has HIV or AIDS, or who you think might have been infected?
☐ Yes ☐ No
4. Had unprotected sex with someone you believe has injected drugs (someone who “shoots up?”)
☐ Yes ☐ No
5. Not properly and carefully used latex condoms with people who might have had HIV?
☐ Yes ☐ No
Did you ever:
1. Inject drugs, steroids, or vitamins, or have a sexual partner who did or does so?
☐ Yes ☐ No
2. Share needles and/or the same cooker, cotton, rinse water, or other possibly contaminated materials?
☐ Yes ☐ No
3. Have multiple sexual partners?
☐ Yes ☐ No
4. Give money or drugs in exchange for sex?
☐ Yes ☐ No
5. Have a sexually transmitted disease (STD) such as gonorrhea, syphilis, Chlamydia, genital herpes or warts, or
have a sexual partner with an STD?
☐ Yes ☐ No
6. Receive transfusion of blood or blood components between early 1978 and nmid-`1985, or have a sexual
partner who did?
☐ Yes ☐ No
7. Have sexual partners who have other sexual partner’s wo did any of the above?
☐ Yes ☐ No
Completed by:
Date:
/
/
(From HIV / AIDS: Is your Adult client at Risk? A pocket tool for Substance Abuse Treatment Providers)
Page 12 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Testing Services
HIV/AIDS—Hepatitis—Tuberculosis
Please call for a confidential appointment with the Facility most convenient to you.
Camden County
Camden County Health Dept.
Blackwood, NJ
(856) 374-6370
Cumberland County
Community Health Care, Inc.
Bridgeton, NJ
(856) 451-4700
GLOUCESTER COUNTY
Gloucester County Health Dept.
Turnersville, NJ
(856) 262-4100
Cumberland County
Community Health Care, Inc.
Vineland, NJ
(856) 794-7191
FamCare
Glassboro, NJ
(888) 794-1235
Division of Youth Family Services
1000 Howard Boulevard
Mount Laurel, NJ 08054
(800) 847-1741
SOUTH JERSEY AIDS ALLIANCE
Toll Free: (800) 281-2437
FamCare
Bridgeton, NJ
(856) 451-3361
FamCare
Vineland, NJ
(856) 451-3361
Home Health Care Services of NJ
Salem, NJ
(856) 878-6000
SALEM COUNTY
Salem County Health Dept.
Salem, NJ
(856) 935-7510
Client Name
Date:
/
/
Page 13 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
HIPAA Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access
to this information. Please review this notice carefully.
Understanding Your Protected Health Information (PHI)
When you visit us, a record is made of your symptoms, examinations, test results, diagnoses, treatment plan, and other
mental health or medical information. Your record is the physical property of the medical health care provider. The
information within belongs to you. Being aware of what is in your record will help you to make more informed decisions
when authorizing disclosures to others. In using and disclosing your PHI, it is our objective to follow the Privacy Standards of
the Federal Health Insurance Portability and Accountability Act (HIPAA) and rudiments of state law.
Your Mental Health and/or Medical Record serves as:







A basis for planning your care and treatment.
A means of communication among the health professionals who may contribute to your care.
A legal document describing the care you received.
A means by which you or a third-party payer can verify that services billed were actually provided.
A source of information for public health officials charged with improving the health of the nation.
A source of data for facility planning and marketing.
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Responsibilities of My Friend’s House
We are required to:

Maintain the privacy of your PHI as required by law and provide you with notice of legal duties and privacy practices
with respect to the PHI that we collect and maintain about you.

Abide by the terms of this notice currently in effect. We have the right to change our notice of privacy practices and
to make the new provisions effective for all protected health information that we maintain, including that obtained
prior to the change. Should our information practices change, we will post new changes in the reception room and
provide you with a copy. Notify you if we are unable to agree to a requested restriction.

Use or disclose your health information only with your authorization except as described in this notice.
Your protected Health information (PHI) Rights
You have the right to:

Review and obtain a paper copy of the notice of information practices and your health information upon request. A
few exceptions apply. Copy charges may apply.

Request and provide written authorization and permission to release PHI for purposes of outside treatment and
health care. This authorization excludes psychotherapy notes and any audio/video tapes that may have been made
with your permission for training purposes.

Revoke your authorization in writing at any time to use, disclose, or restrict health information except to the extent
that action has already been taken.

Request a restriction on certain uses and disclosures of PHI, but we are not required to agree to the restriction
request. You should address your restriction in writing to the Privacy Officer by asking for name of Privacy Officer,
address, and phone. We will notify you within 10 days if we cannot agree to the restriction.

Request that we amend your health information by submitting a written request with reason supporting the request
to the Privacy Officer. We are not required to agree with the requested amendment.

Obtain an accounting of disclosures of your health information for purposes other than treatment, payment,
healthcare operations, and certain other activities for the past six years but not before April 14, 2003.

Request confidential communications of your health information by alternative means or at alternative locations.
Page 14 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Patient HIPAA Consent Form
I understand and read that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I
have certain rights to privacy regarding my protected health information. I understand that this information
can and will be used to:
 Conduct, plan and direct my treatment and follow-up amount the multiple healthcare providers who
may be involved in the treatment directly and indirectly.
 Obtain payment from third-party payers.
 Conduct normal healthcare operations such as quality assessments and physician certification
I have been informed by your or your Notice of Privacy Practices containing a more complete description of
the uses and disclosures of my health information. I have been given the right to review such Notice of
Privacy Practices prior to signing this consent. I understand that this organization has the right to change its
Notice of Privacy Practices from time to time and that I may contact this organization at the address above
to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed
to carry out treatment, payment or health care operations. I also understand you are not required to agree
to my requested restrictions, but if you do agree that you are bound to abide by such restrictions.
I understand that I my revoke this consent in writing at any time, except to the extent that you have taken
action relying on this consent.
Client’s Name (Please Print)
Signature
Date:
/
/
Date:
/
/
Counselor Intern’s Name/Title
Signature
Page 15 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Consent for Treatment
I, (insert name)
Friend’s House to provide substance abuse treatment for
and my family.
hereby give permission to My
This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon,
and will otherwise expire six (6) months from date of discharge.
Client’s Name (Please Print)
Signature
Date:
/
/
Date:
/
/
Date:
/
/
Parent/Guardian (Please Print)
Signature
Counselor Intern’s Name/Title
Signature
This information has been disclosed to your from records whose confidentiality is protected by federal laws. Federal
Regulation (42 CFR – Part 2) prohibits you from making any further disclosure of it without the specific written consent
of the person to whom it pertains, or as otherwise permitted by such regulations. A general Authorization for the
release of medical or other information is NOT sufficient for this purpose.
Page 16 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Clients Rights and Limits of Confidentiality
As a client at our clinic, you have the right to the following:
1. Be informed of your rights verbally and in writing
2. Give informed consent acknowledging your permission for us to provide treatment.
3. To seek counseling services at a reduced cost, provided you produce verification for financial status or
other documentation displaying evidence of financial need.
4. Receive written information about fees, payment methods, co-payment, length and duration of
sessions and treatment.
5. To be free from physical restraint and/or isolation except where an emergency situation would
necessitate such action.
6. Be provided a safe environment, free from physical, sexual, and emotional abuse.
7. Receive complete and accurate information about your treatment plan, goals, methods, potential risk,
and benefits and progress.
8. Receive information about the professional capabilities and limitations of any clinician(s) involved in
your treatment.
9. Be free from audio or video recording without informed consent.
10. Have the confidentiality of your treatment and treatment records protected. Information regarding
our treatment will not be disclosed to any person or agency without your written permission except
under circumstances where the law requires such information to be disclosed. You have the right to
know the limits of confidentiality and the situation in which the therapist/agency is legally required.
11. Have access to information in your treatment records:
a. With the approval of the clinic director during your treatment.
b. To have information forwarded to a new therapist following your treatment at this facility.
c. To challenge the accuracy, completeness, timeliness, and/or relevance or information in your
record, and the right to have factual errors corrected and alternative interpretations added.
12. File a grievance if your rights have been denied or limited. You can initiate a complaint either verbally
or in writing to the grievance officer. You have the right to receive information about the grievance
procedure in writing.
13. To have your civil rights respected and protected at all times during your contact with My Friend’s
Hou8se.
14. To participate fully with your primary counselor in the development and ongoing revision of your
personal treatment goals established within your individual treatment plan.
15. To inquire about all services provided by My Friend’s House as well as other agency-wide services
provided to My Friend’s House.
16. To request the contents of your counseling file including any correspondence you request be written
on your behalf. Your request will bring about a clinical staff review of your file and the manner in
which the information will be released to you within a period not to exceed two (2) weeks.
Page 17 of 25
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371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Client’s Responsibilities & Program Policies
Attendance
You have the responsibility to maintain consistent
attendance at all scheduled counseling sessions. If you
are unable to attend a scheduled session, it is your
responsibility to contact your primary counselor 24
hours in advance and reschedule at a mutually agreed
upon time.
Confidentiality
You have the responsibility to uphold the guidelines of
confidentiality and respect the rights of other clients
who may be participating with you in treatment.
Common rule is “what’s shared at My Friend’s House,
stays at My Friend’s House.”
Agency Regulations
You have the responsibility to become familiar with and
to abide by all agency rules concerning client conduct
while on My Friend’s House’s premises.
Payment for Services
You are responsible for paying for services as they are
rendered to you. The fee you are responsible for paying
will be established based on the type of service you are
receiving and your financial standing. If you wish to
inquire about a reduced rate, it is your responsibility to
provide My Friend’s House with whatever financial
information may be necessary to verify need for
assistance.
Conditions for Successful Discharge from Treatment
Program
Completion of your individual treatment plan and goals
set froth therein, to the satisfaction of both you and
your counselor.
Displaying the ability to remain free of substance use for
a sustained period of time, and the ability to established
counter behaviors that benefit your personal and social
functioning.
Client Confidentiality
In accordance with the updated Confidentiality
Regulations of Drug and Alcohol Abuse Patient Records
dated June9, 1987, you have the right of confidentiality
of counseling sessions, Counselors are however,
required to report knowledge or suspicion of the
following instances to the proper authorities.
1. It is necessary to protect you or someone
else from imminent physical harm
2.
We receive a valid court order or subpoena
that mandates were release your
information
3.
You are reporting abuse of children, the
elderly, or persons with disabilities.
Clinicians within the agency may, at times, consult with
each other regarding your treatment in order to provide
you with the best possible service. To meet your need.
My Friend’s House is a drug free, safe therapeutic environment
My Friend’s House has a zero tolerance for any illicit chemicals and or alcohol being on the premises of this facility and or
within any agency vehicle. In keeping with the policy we reserve the right to have all program participants adhere to
random and dignified search or their person and personal properties. This includes a non-intrusive pat down search
conducted by female for females or male for males strictly.
Random drug free searches may be conducted at any time that program participant(s) enters onto the premises and or
into agency vehicles. Anyone found to be in direct violation of this drug free policy is subject to immediate suspension
and/or being reported to all Necessary legal authorities. My Friend’s House Agency Drug Free Search and Safety Policy is
now part of our standard policy and procedure effective immediately.
This is to acknowledge that I have read, understood, and agreed with the above information.
Client’s Name (Please Print)
Signature
Date:
/
/
Date:
/
/
Counselor Intern’s Name/Title
Signature
Page 18 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Group Rules
1. Group will start on time and end on time
2. Clients must sign in upon arrival
3. Meeting slips must be presented weekly
4. D&A clients must attend 12 step meetings
5. All Clients must get sponsor/home group
6. All Clients must submit to random urines
7. No drug or alcohol used wile in program
8. No intimidation or threatening (physical or verbal) of any kind
9. No profanity or disrespect will be tolerated
Client’s Name (Please Print)
Signature
Date:
/
/
Date:
/
/
Counselor Intern’s Name/Title
Signature
Page 19 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Conditions for Immediate Suspension from Program Participation
1. Being in the possession of, under the influence of, or with the intent to distribute drugs or alcohol
while in the building or surrounding grounds of My Friend’s House.
2. Carrying a weapon of any kind in the building, or creating a physical threat to the wellbeing of staff or
clientele either intentionally or unintentionally.
3. Sexual advances or harassment of staff member, participating client and/or visitor of My Friend’s
House involvement in a relationship with any staff member, which is deemed to be outside the ethical
boundaries of therapeutic relationship.
4. Destroy, vandalizing, or stealing property of My Friend’s House, its employees, clients or visitors.
5. Evidence of a breach of confidentially against another participant of treatment service.
6. Indication of intimidation of any kind (verbal, physical, confrontations or threats) while at My Friend’s
House towards staff, clients or other visitors.
If you are found to be in violation of agency guidelines in any of the aforementioned areas, and investigative
review of your case will be may by the Director of My Friend’s House and a decision will be made concerning
your status with My Friend’s House.
I,
have read the outlined client rights and responsibilities and am
satisfied that they are fair. I agree to the terms herein and have made a decision to accept the treatment
services provided by My Friend’s House.
Client’s Name (Please Print)
Signature
Date:
/
/
Date:
/
/
Counselor Intern’s Name/Title
Signature
Page 20 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Right to be Referred
Treatment agencies, such as My Friend’s House, who provide substance abuse services and receive Federal
Funding from the U.S. Substance Abuse and Mental Health Services Administration are not to discriminate
against you on the basis of your religious beliefs and practices, or if you refuse to hold a religious belief or to
actively participate in a religious practice.
If you disagree with a treatment provider’s religious or non-religious disposition, you have the right by
Federal Law to be referred to another agency for substance abuse services. No more than a week after
requesting to be transferred, a My Friend’s house counselor will make the referral. The agency of your
choice must be accessible to your and able to provide substance abuse services at a level of care equal to or
greater than what is being received from My Friend’s House. You will be transferred to the agency of your
choice as soon as they are able to receive you.
I,
confirm that I have read the above statement and understand my
rights to refuse to participate in any religious activities that may occur at My Friend’s House, and that I have
the right to ask for referral to another provider whose religious nature is more in accordance with my own
belief.
Client’s Name (Please Print)
Signature
Date:
/
/
Date:
/
/
Counselor Intern’s Name/Title
Signature
Page 21 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Authorization for Release of Information
Name:
Date of Birth:
Address:
City, State, Zip:
Client Name:
Phone #:
☐ I authorize My Friend’s House
To release information to:
[or]
☐ I authorize My Friend’s House
to release information from:
Name of Provider or Facility
Name of Provider or Facility
Address
Address
City, State, Zip Code
City, State, Zip Code
Phone / Fax # (Include area code)
Phone / Fax # (Include area code)
PURPOSE OF THIS REQUEST: (check one)
☐ Healthcare
☐ Insurance Coverage
☐ Personal
TYPE OR RECORDS AUTHORIZED:
☐ Psychiatric / Psychological Evaluation and/or Treatment
☐ Drug / Alcohol Evaluation and/or Treatment
☐ Other
SPECIFIC INFORMATION AUTHORIZED: (select one or more as appropriate)
☐ Assessments
☐ Progress Notes
☐ Diagnostic Impression
☐ Discharge Summary
☐ Treatment Plans
☐ Treatment Summary
☐ Lab Test Results
☐ Other
One-Time Use/Disclosure: I authorize the one-time use/disclosure of the information described above to the person/provider/
Organization/facility/program(s) identified.
My authorization will expire:
☐ When the requested information has
☐ 90 days from this date
☐ Other:
been sent/received
Periodic Use/Disclosure: I authorize the periodic use/disclosure of the information described above to the person/provider/
Organization/facility/program(s) identified as often as necessary to fulfill the purpose identified in this document.
My authorization will expire:
☐ When I am no longer receiving
☐ One year from this date
☐ Other:
services from My Friend’s House
I Understand that:
 I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment.
 I may cancel this authorization at any time by submitting a written request to My Friend’s House, except where a
disclosure has been made in reliance on my prior authorization.
 If the person of facility receiving this information is not a health care or medical insurance provider covered by privacy
regulations, the information sated above could be disclosed.
 If the authorized information is protected by Federal Confidentiality Rules 42CFR, Part 2, it may not be disclosed without
my written consent unless otherwise provided for in the regulations.
 If the medical record information is not sent to another care provider, there may be a charge of the requested recor5ds.
Signature of Client or Representative
Relationship to Client (if requester is not the client)
Date:
☐ Parent
☐ Legal Guardian
/
/
☐ Other
Client or Representative has been provided a copy of this authorization
Page 22 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
My Friend’s House
Client Confirmation of Orientation
I acknowledge that the following information, which is detailed in the Client Orientation Manual, has been
explained to me.

Policies regarding Criteria for Admission, Treatment Services, Successful Completion of Treatment, and
involuntary Discharge.

Behavioral Guidelines and Disciplinary Action may be taken

Client fee schedule and payment fees

My rights and Responsibilities as a client at My Friend’s House

My Friend’s House Privacy Notice

Hours of Operation

HIV services/ /resources that are available

The importance of family / significant other involvement in the recovery process
I have been provided with the Client Orientation manual. I have reviewed this material and fully understand
the contents of the manual to my satisfaction. I will ask my Counselor to review this material again if I have
further questions.
The client was offered a copy of this confirmation: ☐ Accepted ☐ Refused
Client Signature
Date:
/
/
Witness
Date:
/
/
Page 23 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
IME CONSENT FORM
Consent for the Release of Confidential Substance Use Treatment Information
Client Name:
Date of Birth:
Authorization & Acknowledgements
I,
authorize.
(Provider Agency),
University Behavioral Health Care in the capacity of the Interim Management Entity (IME) and the New Jersey
Department of Hunan Services/Division of Mental Health and Addiction Services (NJ DHS/DMHAS) to communicate with
and disclose to one another information about my substance use treatment.
The purpose of the authorized disclosure is to enable
(Provider Agency),
University Behavioral Health Care in the capacity of the Interim Management Entity (IME) and the New Jersey
Department of Hunan Services/Division of Mental Health and Addiction Services (NJ DHS/DMHAS) to provide me with
better, more coordinated treatment and allow for the evaluation and authorization of my treatment. I understand that
the information available to these entities will be exchanged verbally and electronically through the New Jersey
Substance Abuse Monitoring System (NJSAMS), a secure computer network, and that my information will be maintained
in the NJSAMS database system.
I understand that my medical records are protected under federal and state law, including the federal regulations
governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 and the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 & 164, and cannot be disclosed without my written consent
unless otherwise provided for in the regulations.
I understand that I may be denied services if I refuse to consent to a disclosure for the purpose of treatment, payment
or health care operations. I will not be denied services if I refuse to consent to a disclosure for other purposes.
I have been provided a copy of this form.
Description of Information to be Disclosed / Released
All my health information, including my drug and/or alcohol treatment record and records about other conditions,
including medical mental health conditions, for which I might have received treatment.
Term / Expiration / Revocation
This signed Consent will exprire one year from today and will remain in effect until that date. I also understand that I
may revoke this consent at any time, except to the extent that action has been taken in reliance on it.
Signatures
Client Signature
Date:
/
/
Date:
/
/
Date:
/
/
Signature of responsible party if other than client
Describe authority to sign on behalf of Client
Witness Signature
Page 24 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org
371 Glassboro Road, Woodbury Heights, NJ 08097
856-669-6900
856-384-0366
Preliminary Treatment Plan
Client Name
Date:
/
/
Problem: Client referred for IOP Treatment
Goal: Completed Admissions Intake Process
Objectives:
Provide necessary information for admission
Sign required consent and release forms
Measurable Steps:
 Complete DASIE and Intake Information
Group Therapy
x per week
Individual Therapy
x per week
Intervention:
Problem: Client orientation to Treatment
Goal: Completed orientation to IOP/Outpatient Program
Objectives:
Begin to integrate into and Utilize treatment
Sign required consent and release forms
Measurable Steps:
 Client will read Orientation Packet
 Client will review program expectations
 Client will meet program staff
Intervention:
Problem: Desire to change drug, marijuana & alcohol use pattern
Goal: Remain free of alcohol & other drugs by attending appropriate treatment, Self-Help & 12-Step Programs
Objectives:
Begin to develop sober support
Develop a meaningful recovery plan
Measurable Steps:
 Attend AA/NA, Self-Help Meetings
per wk.
 Avoid people, places, and things which impact use
 Develop comprehensive Treatment Care Plan with
primary counselor.
Intervention:
Client Signature
Date:
/
/
Counselor Signature
Date:
/
/
Supervisor Signature
Date:
/
/
Page 25 of 25
My Friend's House | Copyright © 2015 –2016. All Rights Reserved | Effective May 21, 2016 | www.MyFriendsHouseFC.org