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Intake Package

Intake Package

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Published by jirehcounseling
Orientation Package for consumer Intake
Orientation Package for consumer Intake

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Published by: jirehcounseling on Nov 06, 2008
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07/30/2010

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Name: Date Of Birth:
 
BH 902-Orientation Signature Checklist Est. Mar 08
ORIENTATION SIGNATURE CHECKLIST
 Please check the topics your care provider reviewed with you.
I was introduced to Jireh and the Services.I was informed of Jireh’s, the assessors’ and the treatment teams’ qualifications to provide the services.The purpose and process of the assessment was fully explained to me.My family understands how our treatment plan will be developed.My family and I were encouraged to participate in my treatment planning.My consumer rights were explained and a copy given to me.The grievance and appeals procedures were explained and a copy given to me.Jireh provided me with Privacy Practices NoticeI received program Consumer Orientation Brochure on my initial visit which includes mission statement,Hours of Operations, After Hours access, policy on abuse, complaints and grievance procedures, outcomesmanagement system and satisfaction, reporting, medication, open door policy, restraints/seclusions,smoking policy, weapons, illegal/legal drugs, Treatment Team, Service Coordination, Costs of Services,Safety and Advanced DirectivesInformation was presented to me in a manner that was clear and understandable.My care program, treatment team visits and treatment responsibility were fully explained to me.I understand that crisis services will be used for emergencies only.The criteria for transition of my families’ service were explained to me.
Costs of Services
I know how my services are being paid for.I understand that it is my responsibility to inform Jireh of any changes in my insurance coverage.No individual will be denied MRO service because of verified inability to pay, you may be referred to otherresources.Jireh Counseling and Consulting Service does reserve the right to refuse services to any individual who isdetermined to be able to pay but is unwilling to pay according to policy.
Consumer Certification
I certify that all information given to JCCS is a true and complete statement of my financial circumstances,and that the fees to be charged to me have been explained to me. I understand and accept responsibilityfor my share of the cost of my treatment. My signature below gives
Jireh Counseling and ConsultingService, Inc.
the authority to bill and receive payment from any third party Insurance. I understand that Iam responsible for any deductibles and/or co-payments and that payment is expected at the point ofservice.
Assignment of Rights:
I hereby authorize Jireh Counseling and Consulting Service to carry forward anappeal on my behalf, should they so choose, as permitted by law. I understand that this does not obligateor require Jireh Counseling and Consulting Service to carry forward any such appeal, unless they sochoose.I acknowledge that JCCS honors
Advanced Directives
whenever clinically practicable and will provide mewith a referral for legal assistance if requested. Do you have an existing Advanced Directive?[]
yes
[]
no
 
 
Follow Up
I feel that my visit was held in a private and confidential setting.I know who is responsible for my service coordination.
I KNOW WHAT HAPPENS NEXTSignatures
Signature of Consumer/Representative*
 
Date Signed
 
Signature of Care Provider
 
Relationship*Parent/legal guardian’s signature in the case of a minor or custodian’s signature in the case of an adult in custodialcare.
 
 
CR101—Consent to Treatment Est. Mar 08
Consent to Treatment
I do hereby seek and consent to take part in the treatment provided by this agency. Iunderstand that developing a treatment plan with this therapist/team and regularlyreviewing our work toward the treatment goals are in my best interest. I agree to play anactive role in this process. I understand that no promises have been made to me as tothe results of treatment or of any procedures provided by this therapist/team.I am aware that I (or my child) may stop treatment with this therapist/team at any time. Iunderstand that I may lose other services or may have to deal with other problems if Istop treatment. (For example, if my treatment has been court-ordered, I will have toanswer to the court.) I know that I must call to cancel an appointment at least 24 hoursbefore the time of the appointment or as soon as reasonably possible.I am aware that an agent of my insurance company or other third-party may be giveninformation about the type (s), cost (s), and providers of any services I receive.My signature below shows that I understand and agree with all of these statements.
 ___________________________________ _______________ Print Name of Consumer Date ___________________________________ _______________ Signature of Consumer Date(or person acting for consumer) ______________________________________ Relationship of Person Acting for Consumer
I, the therapist, have discussed the issues above with the consumer/family (and/or his orher parent, guardian, or other representative). My observations of this person’s behaviorand responses give me no reason to believe that this person(s) is not fully competent togive informed and willing consent.
 __________________________________ ________________ Signature/Title/Credentials Date
 
 
Your Rights as a Consumer
Of Jireh Counseling and Consulting ServicesMental Health, Developmental Disabilities, and Addictive Diseases
 
State and Federal laws protect your rights as a consumer of Jireh Counseling and Consulting Services treatmentprograms. Below is a simplified outline of those rights:
Your rights include: 
The right to receive care suited to your needs.
The right to receive services that respect your dignity and protect you health.
The right to pertinent information, including the benefits and risks of your treatment, in sufficient timeto make informed decisions.
The right to participate in planning your own program, and the right to request choice over thecomposition of the service delivery team.
The right to refuse service, unless a physician or licensed psychologist feels that refusal would beunsafe for you and others.
The right of referral to legal entities for appropriate representation, and to self-help and advocacysupport services.
The right to prompt and confidential services even if you are unable to pay.
The right to request an opportunity to inspect, copy, and correct your records).
The right to exercise all civil, political, personal, privacy and property rights to which you are entitledto as a citizen.
The right to remain free of physical restraints or time-out procedures unless such measures arerequired for providing effective treatment or for protecting your safety or the safety of others.
The right to be free of physical abuse, including sexual abuse, and physical punishment.
The right to remain free of psychological abuse, including humiliating, threatening, and exploitingactions.
The right to file a complaint if you think any of these rights have been restricted or denied.Information on how to file a complaint or contact your Consumer's Rights Representatives ispresented on a poster near the reception desk.
CR100—Consumer Rights RevOct 08

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