TREATMENT CONSENT - ADULT PSYCHIATRIC REHABILITATION ( PRP)
  • This agreement outlines the terms of your participation in the Psychiatric Rehabilitation Program ("Program") offered by Anchortees Health Inc. By signing below, you acknowledge receipt of this agreement and your voluntary consent to participate in the Program.

    Services: Life & Coping Skill Trainings

    Health & Wellness Education Social Skills

    Development Housing Support Services

    Employment & Vocational Support

    Family and Natural Support Involvement

    Educational & Peer Group Support

    Crisis Intervention and Safety Planning

    Recreational & Leisure Activities

    Care Management
  • Client Responsibilities:

    • Attendance: Timely attendance at all scheduled appointments is essential. If unable to attend due to unforeseen circumstances, please notify your counselor immediately to reschedule.

    • Financial Obligations: You are responsible for adhering to the established payment policy outlined by the Program.

    • Professional Conduct: Maintaining a respectful and professional environment is crucial. This includes courteous behavior towards staff and fellow participants and responsible treatment of program facilities.

    • Medication Management: If prescribed medication, you agree to adhere to the doctor's instructions regarding use and storage. Sharing or misusing medication constitutes a serious violation and may result in program termination.

    • Substance-Free Environment: The Program upholds a strict substance-free environment. Abstention from alcohol, illicit drugs (including opioids, marijuana, cocaine), and other unauthorized substances is mandatory. This includes prescribed medications not authorized by your Program doctor. Random urine samples and/or blood alcohol level checks may be requested.

    Confidentiality

    We respect your privacy. All treatment information will be maintained confidentially except in the following instances:

    • Treatment Team: Information may be shared with other professionals directly involved in your care to ensure comprehensive treatment planning.

    • Legal Requirements: Disclosure may be necessary when compelled by a court order or subpoena.

    • Public Health Emergencies: Reporting of specific infectious diseases is mandated by law.

    • Medical Emergencies: Information may be shared with your authorized healthcare provider in case of a medical emergency.

    • Suspected Harm: We are legally obligated to report suspected child abuse/neglect or threats of harm to yourself or others.

    Client Rights and Responsibilities:

    • You have the right to ask questions and actively participate in developing your individualized treatment plan.

    • We will collaborate with you to define your recovery goals and regularly assess progress towards achieving them.

    • Your active participation in treatment activities, including self-monitoring, assigned exercises, and group discussions, is essential for successful program completion.

    Missed Appointments & Non-Compliance:

    We recognize that unforeseen circumstances may arise. If you miss an appointment or encounter difficulties complying with program expectations, please communicate openly with your counselor. We will work collaboratively to address the issue and develop a plan to maintain your progress. However, consistent missed appointments or repeated non-compliance with program rules may lead to program termination.

    Discharge:

    Upon successful program completion, discharge planning will be initiated to ensure a smooth transition to ongoing support services. If you choose to leave the Program prematurely, we will provide referrals to other appropriate resources.

    We are committed to partnering with you on your path to recovery. Together, we can create a successful treatment plan and empower you to achieve your wellness goals.
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  • CLIENT INTAKE

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  • Primary Insurance Carrier’s Information

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  • Emergency Contacts (Please provide contact information for individuals to be reached in case of an emergency):

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  • NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

    PLEASE REVIEW IT CAREFULLY THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US USES AND DISCLOSURES OF HEALTH INFORMATION

    We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

    Our Privacy Practices: Anchorites Health Inc (AHI) is committed to ensuring the highest level of confidentiality for your protected health information (PHI). PHI includes all health data related to you that is stored within our records. We guarantee that this information, whether in whole or in part, will not be disclosed to any individual or entity without your explicit consent. Moreover, our services are delivered in a manner that prioritizes confidentiality. Any collaboration with primary care physicians, referring agencies, schools, or other stakeholders will only take place with your written consent.

    Federal & State Laws: In compliance with federal regulations, specifically the "HIPAA Privacy Regulations," we are obligated to safeguard the confidentiality of your health information. Furthermore, we must adhere to state laws, which often impose stricter requirements than federal regulations. This dual compliance framework ensures heightened protection for your sensitive information.

    Authorization to Disclose PHI: It is our standard procedure to request your authorization or consent prior to disclosing your PHI to any individual or entity. You have the right to revoke this authorization or consent at any time and for any reason.

    How We Use Your Protected Health Information: We utilize your Protected Health Information (PHI) solely for the purposes of treatment, payment, and healthcare operations. For example, we may use your PHI to plan and deliver your care, communicate with other healthcare professionals involved in your treatment, facilitate payment for our services, educate and train our staff, and evaluate and improve the quality of our services. Additionally, we are permitted to use or disclose your health information as required by law.

    Your Rights: You retain the right to request limitations on specific uses and disclosures of your PHI; examine and duplicate your PHI; request modifications to your PHI; and receive an account or summary of disclosures of your PHI. However, this access excludes records from external agencies, such as hospitals or DOR, which require authorization from the Program Director, with a notation of the date and time entered in the file. If accessing the file is deemed not to be in the member's best interest, a written summary of the file contents will be provided. A staff member must be present during the member's review of the record to ensure the integrity of the contents. Members who dispute their records may submit corrections or amendments, which will be incorporated into the records.

    Research: Recording sessions or reviewing information for research purposes will not occur without the client's written consent.

    Marketing Health-Related Services: We will not utilize your health information for marketing communications unless we have obtained your written authorization.

    Abuse or Neglect: We reserve the right to disclose your health information to the relevant authorities if we suspect abuse or neglect.

    Appointment Reminders: We may utilize or reveal your health information to send you appointment reminders, which may include voicemail messages, text messages, emails, postcards, or letters.

    Our Duty: It is our responsibility to provide you with a copy of this disclosure statement for your records during intake. Upon request, a duplicate can be provided to you at any time. Generally, our conversations are treated with confidentiality, as guaranteed by state law, federal regulations, and our code of ethics. However, there are certain circumstances where confidentiality cannot be assured. These situations include:

    Notification of appropriate parties if we have reason to believe you may harm another individual.

    Reporting any instances of child abuse (past or present), or the abuse, neglect, or exploitation of the elderly.

    ● Compliance with a subpoena accompanied by a court order.

    ● Response to any situation where we believe you may pose a threat to yourself.

    CLIENT RIGHTS

    As a client, you have certain rights that we aim to uphold. You have the right to a comprehensive assessment of your behavioral health needs, ensuring that we provide a tailored approach to your specific situation. You are also entitled to actively participate in developing a written treatment plan that addresses your unique requirements. This plan should include evidence-based treatment modalities delivered by qualified professionals in a safe and respectful environment. Whenever possible, we prioritize minimizing medication use in your treatment plan.

    In addition to the above, you have the right to receive treatment in the least restrictive setting that effectively addresses your needs. We will ensure a smooth transition to appropriate follow-up care upon discharge so that you can continue to receive the care you need even after leaving our facility.

    Access: You are entitled to view or obtain copies of your health information, with a few exceptions. If you request copies, we will apply a reasonable fee to cover the costs of locating and copying your information, as well as postage if you prefer the copies to be mailed to you.

    Amendment: You have the right to request amendments to your health information.

    QUESTIONS AND COMPLAINTS:

    If you require further information about our privacy practices, or if you have any questions or concerns, please do not hesitate to contact us.

    If you suspect that we may have breached your privacy rights, or if you disagree with a decision we have made regarding access to your health information, or in response to a request for amendment or restriction of use or disclosure of your health information, or to communicate with you through alternative means or at alternative locations, you may file a complaint with us using the contact details provided at the end of this Notice. Additionally, you have the option to submit a written complaint to the U.S. Department of Health and Human Services. Upon request, we will furnish you with the address to file your complaint with the U.S. Department of Health and Human Services.

    We fully support your right to privacy concerning your health information. Rest assured, we will not retaliate in any manner if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. A designated Privacy/Contact Officer is available for this office. You may contact the Privacy Officer by simply reaching out to the office and requesting to speak with the Office Manager, who serves as the Privacy Officer.
  • CLIENT ACKNOWLEDGEMENT OF THE NOTICE OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION

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  • acknowledge that I have either received a copy of this office’s NOTICE OF PRIVACY PRACTICES or that this office’s NOTICE OF PRIVACY PRACTICES was made available to me to receive.
  • consent to the use and disclosure of my personal health information by your office for Treatment, Billing / Payment and Health care operations as outlined in the
    NOTICE OF PRIVACY PRACTICES.
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  • AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

    I, the Undersigned, authorize Anchortess Health Inc. and staff members to release and receive written and/or verbal information related to the client list to the person or agency indicated below:
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  • (one year from date signed)
  • Person/Organization authorized to receive your information

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  • I understand that I can revoke or cancel this authorization at any time by sending a letter to the Privacy Officer of the organization listed above and which is to supply this information. If I do this, it will prevent any releases after the date it is received but cannot change the fact that some information may have been sent or shared before that date. 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 from the professional or facility listed above, nor will it affect my eligibility for benefits. I understand that I may inspect and have a copy of the health information described in this authorization. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by those regulations. I understand that this professional or facility will receive compensation for the use or disclosure of my health information. The arrangement has been explained to me and I understand and accept it. I affirm that everything in this form that was not clear to me has been explained and I now understand all of it.

    I acknowledge that the information to be used or disclosed because of this Authorization may include records that are protected by other federal and/or state laws applicable to substance abuse. I specifically authorize the release of confidential information relating to drug and/or alcohol abuse, psychiatric, HIV results and or AIDS information. The recipient of drug and/or alcohol abuse information disclosed because of this Authorization will need my further written authorization to re-disclose this information. 42 CFR 2.32 restricts any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.

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  • CRISIS MANAGEMENT PLAN

  • A crisis is a sudden change in the client‘s behavior in response to stress or other painful feelings. It is often negative due to the client’s lack of experience or inability to cope with personal or interpersonal problems. The goals of crisis management are to provide immediate emotional support and reduce stress, decrease the risk of harm to the client or others and teach more constructive ways for dealing with stress or other painful feelings. Part of good crisis management is knowing what to expect. A person’s response to stress or negative situations is the same. With that in mind, check the responses that relate to you.

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  • If my crisis remains unresolved despite taking steps, I consent to:

    1. Call a 24-hour crisis hotline: 988 or 301-662-2255.

    2. Go to the nearest Hospital Emergency Room

    3. Call 911

    If/when I call my PRP coordinator or primary therapist (during normal business hours) they may:

    1. Assess my crisis and attempt to assist me in resolution via phone.

    2. If available, my PRP coordinator may transport me to the nearest hospital. If my PRP counsellor is unavailable, my PRP coordinator or therapist will contact my SSP and/or emergency contact person to transport me to ER.

    3. Call 911 on my behalf.

    4. Discuss my crisis and medication with the psychiatrist on staff.
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