Registration & Intake
CONTACT INFORMATION
DEMOGRAPHICS & INTAKE
INFORMED CONSENT:
Except in emergency/crisis situations, Behavioral Health Intervention Center has a legal and ethical obligation to obtain your informed consent before initiating treatment services.
How Treatment Works:
I will be given a clear description from my treatment team members, regarding the clinical characteristics of the presenting problem(s) in a manner in which I can understand.
I. I will be given a clear recommendation for the types of treatment recommended. Recommended treatment may include, but is not limited to, individual therapy, family therapy, couples counseling, group therapy, addictions counseling, case management services, 12-step meetings, medication management, medical service(s) and/or psychiatric services. Times, dates, and session length will be discussed with my treatment team. l understand that at Behavioral Health Intervention Center I am expected to comply with my individual treatment plan and attend all treatment sessions. It is my responsibility to clearly communicate with my therapist and/or treatment team regarding any circumstance(s) that may interfere with my attendance of the program.
II. Risks/Benefits of Treatment: l understand that Behavioral Health Intervention Center cannot guarantee results of substance abuse or mental health services provided. I understand that I am responsible for my participation in my recovery, which will impact the effectiveness of the treatment services provided. I understand that there may be some risks in participating in substance abuse and mental health services. These may include, but are not limited to, addressing painful emotional experiences and/or feelings; being challenged or confronted on particular issues; reuniting with family members; or being inconvenienced due to costs/fees of treatment. I am aware that I can discuss any unforeseen risks or benefits with my treatment team at any time. In the case of medical or psychiatric care, medications, side effects, and alternative treatments will be discussed with the contract physician and/or contract psychiatrist.
III. Fees: l understand that I am responsible for the fees associated with my treatment services. The financial agreement has been discussed with the insurance and billing department and/or Administrator. I agree to pay for my treatment services according to my insurance/financial agreement set forth with Behavioral Health Intervention Center.
IV. Voluntary Treatment: l voluntarily agree to undergo substance abuse and mental health treatment and understand that I may end treatment at any time. If I choose to end treatment, I understand that my treatment team may want to discuss this decision with me, but that I reserve the right to stop treatment at any time. Furthermore, I understand that my treatment team may provide treatment recommendations with which I do not agree, including but not limited to the modality of treatment, duration of treatment and/or frequency of visits.
V. Court and Subpoena Fee I am aware that if my therapist/counselor/assessor is required by a judge or is subpoenaed to appear in court on my behalf I will be responsible for the $250 per hour rate for their time.
STATEMENT OF CONFIDENTIALITY:
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. You have the right to confidentiality and privacy by the group leaders and other group members. Confidentiality within the group setting is a shared responsibility of all members and leaders. While group leaders may not disclose any client communications or information except as provided by law, group members’ communications are not protected. As such, confidentiality within the group setting is often based on mutual trust and respect.
When Disclosure Is Required By Law:
Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect, where a client presents a danger to self, to others, to property, or is gravely disabled., if your counselor becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, he will do whatever he can within the limits of the law to prevent you from injuring yourself or others, to ensure that you receive the proper medical care.
Third Party Payer:
Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. Only the minimum necessary information will be communicated to the carrier. Your psychologist or counselor has no control or knowledge over what insurance companies do with the information he submits or who has access to this information.
Litigation Limitation:
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits,etc...), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on our counselor to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Consultation:
Your counselor consults regularly with other professionals regarding his clients; however, client’s name or other identifying information are never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained.
Your Right to Review Records:
As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when your counselor assesses that releasing such information might be harmful in any way. In such a case, your counselor will provide the records to an appropriate and legitimate mental health professional of your choice.
PRIVACY PRACTICES
Privacy is a very important concern for all consumers as they choose a healthcare provider. It is also a complicated issue because of federal and state laws governing the practice of psychology and the professional ethics that govern the practice of all counselors at the Behavioral Health Intervention Center. In an effort to clarify your rights as a consumer of healthcare, the Behavioral Health Intervention Center has developed the following privacy statement in accordance with HIPAA (Health Insurance Portability and Accountability Act) requirements and guidelines. This statement will outline how the Behavioral Health Intervention Center handles your personal information and how we share your personal information with other professionals and organizations. If you have any questions about our privacy practices, please don’t hesitate to ask your counselor for more precise details.
MEDICAL INFORMATION
Each time you visit a healthcare facility or provider, information is collected about you and your physical or mental health. It may be information about your past, present, or future health or about the treatment or services you received from a healthcare provider. Health information also includes billing and payment data. This healthcare information is called Protected Health Information, or PHI. Your PHI is considered a part of your medical or healthcare record and is stored on site in a file at Behavioral Health Intervention Center.
Protected Health Information included in your Behavioral Health Intervention Center file likely includes:
Relevant history
Presenting problems
Diagnosis
Treatment plan
Progress notes
Records from other providers
Information about medications
Legal matters
Treatment planning
Treatment evaluation
Coordination of care with other providers
Insurance billing
PRIVACY AND THE LAW
HIPAA laws require Behavioral Health Intervention Center to keep your PHI private and to provide you with notice of the legal duties and policies of this clinic (Notice of Privacy Practices). The guidelines outlined in this notice are subject to change. In the event of a change in policy, the new guidelines will apply to all PHI stored at the Behavioral Health Intervention Center.
RELEASE OF INFORMATION WITH CONSENT
When a client requests that the Behavioral Health Intervention Center share information with others for any purpose other than treatment, payment, or health care operations, they are required to sign a release of information form that includes the other party’s name, address, phone number, and the nature of the information to be disclosed. Releases of Information may be revoked (canceled) at any time.
RELEASE OF INFORMATION WITHOUT CONSENT
There are times when the Behavioral Health Intervention Center will disclose your personal health information without your consent or authorization. · When required by law to report suspected child abuse · When you are involved in a legal proceeding or lawsuit and your counselor received a subpoena, discovery request, or other lawful process. In these situations, your counselor will only release information after they attempt to contact you about the request, consult with your lawyer, or attempt to obtain a court order to protect the information requested. · When government agencies request proof that the Behavioral Health Intervention Center are HIPAA compliant. To prevent a serious threat to your health or safety (including suicide) or to the safety of some other person(s). In the event that personal health information is disclosed without your consent, the Behavioral Health Intervention Center keeps records of the specific information released, the recipient of your PHI, and the date it was released.
RELEASE OF LIABILITY
In order to be admitted to and enter the premises of Behavioral Health Intervention Center and/or to participate in any programs offered by Behavioral Health Intervention Center, I agree to the following release of liability and I make the following representations.
I hereby acknowledge the inherent risk in regard to alcohol and other drug abuse and dependency treatment, including but not limited to falls, inattention of staff, actions of other client/guest, and physical injury and accidents which cannot be foreseen. I voluntarily assume all such risk with full knowledge and appreciation of the risk involved.
I hereby assume the risk of any injury that may occur while using any equipment, services and participating in any Behavioral Health Intervention Center sessions. Whether these risks arise from my negligence, the negligence of others or through a non-negligent accident. I release and discharge Behavioral Health Intervention Center, its employees, agents, officers, contractors, heirs, assigns, from liability resulting from any such injuries while participating at Behavioral Health Intervention Center and using all equipment and services on the properties. Further, I freely and voluntarily waive all rights to bring legal action against Behavioral Health Intervention Center, its employees, agents, officers, contractors, landlords, heirs and assigns, arising from my use or presence at Behavioral Health Intervention Center and/or while participating in physical activity programs outside of Behavioral Health Intervention Center premises. I hereby voluntarily assume any and all risk of injury, death, mental and/or physical harm, any property loss and/or damage on and outside of Behavioral Health Intervention Center premises.
ELECTRONIC USE AGREEMENT
Policy Summary
Behavioral Health Intervention Center allows the use of electronics during treatment. It is a privilege with the understanding that clients use their electronics responsibly. Clients will need to adhere to this agreement or electronic use will be revoked. This agreement applies to social media as well.
Client Responsibilities
Client agrees to use their electronics appropriately.
Clients will adhere to HIPAA and will not take any pictures while in treatment. This includes off Behavioral Health Intervention Center premises while participating in physical activities required as part of the treatment plan.
Clients will not use ANY means of electronic communication (this includes social media) to disclose the names or identities of other clients in treatment.
Client must not bring electronics to designated group times.
Client will use appropriate language and volume during phone conversations.
Client will not access pornography on their electronic devices while in treatment.
Clients will not allow electronic use to interfere with treatment at the facility.
NO video communication is allowed while in treatment.
ATTENDANCE POLICY
Participants are responsible for arriving to the scheduled class sessions on time. No participants will be allowed to enter the session 10 minutes after the starting time.
ALCOHOL,AND OTHER DRUGS POLICY
A participant shall not use, purchase, sell, distribute, be under the influence of or possess any kind of alcoholic beverage, controlled substance(as defined by state law), illegal or counterfeit substance or paraphernalia on the property.
DRESS POLICY
Participants will maintain personal attire and grooming standards that promote safety, health, and acceptable standards of social conduct, and are not disruptive to the educational environment; including but not limited to promoting alcohol or other drugs or gang articles of clothing.
PERSONAL PROPERTY POLICY
Cellular Telephones: Cell phones are permitted; however, they should be turned off or on silent during program hours. Cell phone use is not allowed during intervention hours. This includes but is not limited to iPads, MP3 Players, PDAs and other electronic devices capable of peer-to-peer communication and recording audio and/or video/still images. Taking pictures or recording while in the program is prohibited.
FOLLOWING STAFF DIRECTIONS POLICY
Participants will follow the direction of authorized staff members while in the program or participating in a program activity on property. Clients are required to actively participate defined by answering and asking questions, working in groups, and completing all assignments. Clients who refuse to participate will be terminated from the program without a refund, and instructed to transfer to another facility.
Participants will not be allowed to have their head down during program hours. Any participant who does have their head down during the program hours will be asked to leave the program.
VANDALISM POLICY
A participant will not willfully, with or without malice, participate alone or with others to damage or destroy property of another, including property belonging to BHIC, staff, clients, other adults on BHIC property.
THEFT/ROBBERY POLICY
A participant will not take, threaten or attempt to take or possess the property of others, or participate with others to do so.
WEAPONS AND DANGEROUS OBJECTS POLICY
A participant will not possess, handle, transport or use any weapon, object that can be reasonably considered a weapon, dangerous object or substance that could cause harm or irritation to another individual on property or at any program function.
PAYMENT POLICY
I understand and agree that I am financially responsible for payment of all services received in the amount stated above. I agree to pay that total in full. I understand that any remaining balance not paid in full, will result in not receiving a certificate of completion for the services I received.
Not adhering to the above policy is grounds for dismissal from the Behavioral Health Intervention Center.
Client Rights Policy
To receive considerate and respectful care, regardless of race, gender, ethnicity, sexual orientation, creed, religion, age, nationality, or physical disability.
To be informed of the risks/benefits of any treatment recommendations.
To participate in any treatment decisions as it relates to your care.
To refuse treatment.
To individualized treatment.
To have your privacy protected unless otherwise permitted by you or state and/or federal law.
To request any information in your client record unless it is determined that such information would be detrimental to your care.
To know about any fees and cost’s of care prior to initiation of any services offered by the provider.
To know the qualifications and educational background of the person treating you.
To be informed by the provider in advance of any decision to terminate the therapeutic relationship with you.
To know that your treatment will be terminated if you commit a crime on the premises, when your welfare or the welfare of others are threatened by your continued participation in the program.
To appropriate referral, if necessary, when you are discharged form the program.
To be free from unwarranted invasion of privacy.
To be protected form harm, abuse, and exploitation.
To receive accommodations in accordance with the American Disabilities Act (ADA) and/or as required by law.
To expect the provider to make a reasonable response to your requests.
To file a complaint against the provider without retaliation from the provider.
Grievance Policy:
I understand that if I have a complaint/grievance, I should first contact Christopher Matthews, Owner and Clinical Director at 704-712-1696 or send a email to [email protected] .
I understand that I have a right to contact the agencies below at any time to discuss my complaint/grievance in the event Chris Matthews is unable to resolve my issue:
DWI Services, Justice Systems Innovations NC Mental Health/Developmental Disabilities/Substance Abuse Services
Donna Brown [email protected]
3008 Mail Service Center Raleigh, NC 27699-3008
Phone: 984-236-5256
Fax: 919-508-0963
North Carolina Substance Abuse Professional Practice Board
http://www.ncsappb.org/wp-content/uploads/2012/11/complaints.pdf
Katie Gilmore, Associate Executive Director
P.O. Box 10126 Raleigh, NC 27605
Disability Rights NC
http://www.disabilityrightsnc.org/ [email protected]
3724 National Drive, Suite 100 Raleigh, NC 27612
(877) 235-4210 or (919) 856-2195
Visits and Fees
PAYMENT POLICY
1. Each DWI Assessment will cost $100 per assessment to include one e508 form per assessment.
2. Each additional e508 form created for multiple DWI offenses will cost $100.
3. Each DWLR will cost $100 per assessment to include one e508 form per assessment
4. ADETS for North Carolina DWI state regulated at $160 plus $25 for Prime for Life Workbook.
5. Level I Short term group outpatient treatment will cost $20 per hour.
6. Level II Long term group outpatient treatment will cost $20 per hour.
7. Individual Therapy Sessions will cost $100 per hour.
8. Family Therapy Sessions will cost $150 per hour.
9. Out of State Prime for Life will cost $320.
10.Out of State Reviews will cost $250
11. North Carolina DWI In State Review will Cost $150
12. North Carolina Driving Record will cost $13.75
13. Child Custody, DSS, Mental Health, or School/University Substance Abuse Assessments will cost $250
I acknowledge that the information above is correct. By signing this form I am authorizing Behavioral Health Intervention Center, LLC to charge my card for all fees listed above. I also acknowledge and accept the Refund, Cancellation, and Rules Program stated by Behavioral Health Intervention Center, LLC.