Consent of Participation

INNOVATIVE THERAPEUTIC SERVICES, CORP

OUTPATIENT MENTAL HEALTH CLINIC

CONSENT OF PARTICIPATION

I, ______, agree to participate in therapy.
(Print Name)
I hereby give consent for the services to be provided. I have been informed of the services that will be
rendered to include but not limited to:

Individual Therapy

Family Therapy

Group Therapy

Psychiatric Services

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Client SignatureDate

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Parent/Guardian Signature (if applicable)Date

CLIENT INTAKE

Referral Date:______Referral Source:______

Client Name:______Client DOB:______

Client Social Security #:______-____-______Medical Assistance #(if applicable): ______

Address:______

StreetCityStateZip

Phone: (home) ______(cell) ______(business)______

Primary Care Doctor:______

(Name)(Phone Number)

Address: ______

StreetCityStateZip

Case Manager (if applicable): ______

(Name)(Phone Number)

Primary Insurance Carrier’s Information

Name: ______DOB:______Insurance Customer Service #: ______
Member ID Number:______Group Number (if applicable):______

Emergency Contacts (please provide information for those who may be contacted in case of an emergency):

Name: ______
Address: ______

Phone Number: ______

Name:______
Address: ______

Phone Number: ______

*Name: ______
Address: ______

Phone Number: ______

*If client is a minor, please complete a third emergency contact.*

CONSENT FORM

CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATION

This form is an agreement between you, ______and Innovative Therapeutic Services. (Print client name)

When we examine, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.

By signing this form you are agreeing to let us use your information here and send to it others. The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information. By signing this form you are agreeing to let us use your information here and send it to others. The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information. By signing this form you are acknowledging that you have received a copy of the Innovative Therapeutic Services Notice of Privacy Practices. Please read the Notice of Privacy Practices before you sign this Consent Form.

In the future we may change how we use and share your information and so may change our Notice of Privacy Practice. If we do change it, you can get a copy by contacting our office at 301-604-1458, Mon. – Fri. 8:30 am – 4:30 pm.

If you are concerned about some of your information, you have the right to ask us to not use or share some of your information for treatment, payment or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with your wishes.

After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on but we may already have used or shared some of your information and cannot change that.

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Signature of client or personal representativeDate

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Printed name of client or personal representativeRelationship to client

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Description of personal representative’s authority

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

I, the Undersigned, authorize: Innovative Therapeutic Services

To allow the use and sharing of protected health information about:

Client name: ______Date of Birth: ______

Once completed and signed, this authorization will remain in effect until: ______
(one year from date signed)

The Mental Health Information Authorized for Release includes: (check all that apply)

□ Copies of Records□ Discharge Summaries□ Consultation

□ Immunization Records□ Other Information: ______

Person/Organization authorized to receive your information:

Primary Care Doctor: ______

Address: ______

Phone #: ______Fax #: ______

Purpose of Release: ______

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 at number 4 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 believe I now understand all of it.

I acknowledge that the information to be used or disclosed as a result 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 as a result 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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Client/Parent/Guardian SignatureDate

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Print NameDate

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

I, the Undersigned, authorize: Innovative Therapeutic Services

To allow the use and sharing of protected health information about:

Client name: ______Date of Birth: ______

Once completed and signed, this authorization will remain in effect until: ______
(one year from date signed)

The Mental Health Information Authorized for Release includes: (check all that apply)

□ Copies of Records□ Discharge Summaries□ Consultation

□ School Visitation□ Immunization Records

□ Other Information: ______

Person/Organization authorized to receive your information:

School: ______

Address: ______

Phone #: ______Fax #: ______

Purpose of Release: ______

______

Client/Parent/Guardian SignatureDate

______

Print NameDate

ADULT CRISIS MANAGEMENT PLAN

Client’s Name: ______

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 inter-personal 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. Generally, a person’s response to stress or negative situations is the same. With that in mind, check the responses that relate to you.

When I am upset, I typically: ______.

____ Use profanity (ie: cursing, swearing, vulgar language)
____ Makes verbal or physical threats (ie: violating personal space)
____Has a rage reaction (ie: temper tantrum, screaming, door slamming)
____Tries to hurt others (ie: hits, kicks, bites, spits, pushes, etc.)
____ Tries to hurt himself/herself
____ Destroys property
____ Makes bad decisions
____ Uses drugs or alcohol
____ Seeks out weapons or other harmful objects
____ Targets or starts fights or arguments with others
____ Demands to be left alone/isolates
____ Makes homicidal threats (“I’m going to kill____.”)
____ Makes suicidal threats (“I’m going to kill myself.”)

Other: ______.

TIPS that I can use to safely manage a crisis:

___ Take a deep breath and recognize crisis by putting into prospective.
___ Try to control my behavior to harm self/others by taking a personal “time-out.”
___ Avoid drugs or alcohol.
___ Avoid use of all weapons.
___ Avoid threats/altercations with others by walking away from upsetting situations.
___ Call your Social Support Partner (SSP) or emergency contact person:

Name: ______Phone #:______

___ Call your PRP coordinator or primary therapist (during business hours).
___ Call the ITS crisis line: 301-604-1458 (after business hours).
___ Other: ______

If my crisis has not been resolved after following the actions above, I agree to:

Call a 24-hr crisis hotline City/410-931-2214 County/410-435-5717
Go to nearest Hospital Emergency Room
Call 911

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

Assess my crisis and attempt to assist me in resolution via phone.
If available, my PRP coordinator may transport me to nearest hospital. If my PRP counselor is unavailable, my PRP coordinator or therapist will contact my SSP and/or emergency contact person to transport me to ER.
Call 911 on my behalf.
Discuss my crisis and medication with psychiatrist on staff.

Client Signature:______Date:______

ITS Staff Signature:______Date:______

CHILDCRISIS MANAGEMENT PLAN

Child’s Name: ______

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

When my child is upset, he/she:

____ Uses profanity (i.e.: cursing, swearing, vulgar language)____ Demands to be left alone

____ Destroys property ____ Runs away____ Ignores rules or directions

____ Refuses to talk to anybody/Will only talk to______

____ Makes bad decisions____ Uses drugs or alcohol

____Tries to hurt others (i.e.: hits, kicks, bites, spits, pushes, etc.)____ Tries to hurt him/herself

____ Targets or starts fights or arguments with others____ Seeks out weapons or other harmful objects

____ Makes verbal or physical threats (i.e.: violating personal space)

____Has a rage reaction (i.e.: temper tantrum, screaming, door slamming)

____Challenges authority (i.e.: talks back to parents, teachers, police, etc.)

____ Makes homicidal threats (“I’m going to kill____.”)____ Makes suicidal threats (“I’m going to kill myself.”)

Other:______

I manage my child’s behavior by:

____1.Control the space where he/she is acting out.

____2.Acknowledge feelings and give him/her time and space to vent.

____3.Don’t take it personal. Ignore negative comments.

____4.Look for chances to reinforce good decisions. (If he/she has stopped using profanity, acknowledge that they are communicating more appropriately).

____5.Get a feel for when the child is ready to hear me.

____6.Present the child with my expectation(s) and offer to help. For example, “You know you’re going to have to clean that up; do you want me to get the broom?”

____7.When the child is calmer, take time immediately to review what just happened and discuss better ways that the child could deal with the situation “next time”.

____8.Let the child know that you will be looking to see him/her put the new plan into action next time.

Other:______

If the client should exhibit behaviors that pose harm to his/herself or others, staff will:

Limit client’s access to weapons or items that can be used as weapons;
Remove the person(s) who is/are the current target;
Offer the client options and set limits;
Use verbal interventions and proximity control to help the client deescalate, and;
Assist the client with reintegration.

Should unsafe behavior(s) persist, staff will:

Contact Clinical/PRP Director at (301) 604-1458 (during business hours)
Contact our after hours crisis number at (301) 509-4720
Contact 911
Transport or refer client to closest Emergency Room

Parent/Guardian’s Signature:______Date:______

ITS Staff Signature:______Date:______

ADVANCED MENTAL HEALTH DIRECTIVES

(Applicable if Age 16 or Older)

I,______, have received information regarding Advanced Mental Health Directives.

Please Check One:

I currently have an Advanced Mental Health Directive and have given ITS a copy.

YesNo

IF YOU DO NOT HAVE AN ADVANCED MENTAL HEALTH DIRECTIVE AND WOULD LIKE ONE, PLEASE HAVE YOUR THERAPIST/COUNSELOR TO ASSIST YOU IN MAKING AN ADVANCED MENTAL HEALTH DIRECTIVE.

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Client (Age 16 or older)Date

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Parent/Guardian (if applicable)Date

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IT Staff SignatureDate

ACKNOWLEDGMENT OF RECEIPT OF CLIENT HANDBOOK

Client Name: ______DOB: ______

Check boxes to verify that you have read and received a copy of the following, located in the client handbook:

____ Notice of Privacy Practices and Confidentiality Agreement

____ Explanation of Mental Health Procedures

____ Notice of Rights & Responsibilities

____ Discharge Procedure

Acknowledgement: Please sign below to indicate that you have received a copy of the client handbook.

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Client/Parent/Guardian’s SignatureDate

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Print Name

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ITS Staff SignatureDate

POLICY ON FINANCIAL OBLIGATIONS

Fees and Financial Obligations

Prior to consenting to treatment Innovative Therapeutic Services (ITS) will discuss the estimated cost of payment and payment options with the client. ITS billing policy states that if a client does not have insurance coverage, the client may be billed by Innovative Therapeutic Services, CORP. For clients with insurance, services will be billed by Innovative Therapeutic Services through the client’s insurance company. It is the client’s responsibility to know their insurance benefits and whether or not the services they are to receive are a covered benefit. The client will be responsible for any co-pay or balance due thatInnovative Therapeutic Services is unable to collect from the insurance carrier for whatever reason.If there is a copay, copays are collected at the time of service.

Cancellations and Missed Appointments:

When an appointment is scheduled, that time is reserved specifically for you. If the appointment is missed or cancelled without enough notice, the therapist is unable to make use of that time. Therefore, sessions must be cancelled 24 hours in advance. If a client does not give 24 hours notice it is considered a “no show”. If a client no shows two times consecutively the client will have to wait 30 days before being able to schedule a follow up appointment, unless the client is experiencing a mental health crisis.

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Client/Parent/Guardian’s Name

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Client/Parent/Guardian’s SignatureDate

Revised 6/2016