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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 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 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