Professional Rehabilitation Consultants
Zan L Liccione, MDiv MSRC, CRC, QP
CEO clinical services
Guilford Center and Alamance-Caswell LME
Mashunda F Famble, MSRC, CRC, QP
CEO clinical services
Centerpoint Human Services
2007 Yanceyville Road, Suite 3311, Box 40 Greensboro, NC 27405
Main telephone 336-543-6970
Our Mission:
to provide professional services and supports to consumers with diagnoses of mental retardation, developmental delays, mental health concerns and substance abuse issues in an effort to advocate for and enhance empowerment of persons with disabilities as they increase their integration in our communities.
Our Values:
At Professional Rehabilitation Consultants, we believe that persons with disabilities:
- Deserve respect and have dignity intrinsic to all human life and as shall be treated as such;
- Have specific gifts of self to contribute to our world and shall be encouraged to share these gifts in their interactions in the wider community in which they live;
- Have the right to live in the least restrictive environment in which they can reach their goals and develop independence;
- Have the right to expect professional, excellent support services in an effort to most effectively reach their goals and fulfill their plans of care, to this end PRC will hire the most suitable staff for the individual person and his/her needs, as outlined in the plan of care.
- Has the right to superior advocacy in order to enhance each individual’s empowerment and voice in the community and wider world.
- Has the right to access as guaranteed under the Americans with Disabilities Act of 1990 and the Civil Rights Act of 1964;
Our Vision:
At Professional Rehabilitation Consultants, we strive to reach the following:
- To provide all our consumers and their natural supports with the best services possible in the most appropriate setting;
- To select staff who demonstrate professional skill levels and are an excellent match for provision of services to the individual;
- To meet and surpass current standards of best practices as outlined by the North Carolina Department of Health and Human Services;
- To always provide person first services, using person first language and upholding a commitment to educating the general public about the dignity of all persons with disabilities.
Professional Rehabilitation Consultants
FACE SHEET & EMERGENCY MEDICAL INFORMATION
Consumer Name: ______Admission Date: ______
Record Number : ______Discharge Date: ______
Medicaid Number: ______DOB: ______
Home Address: ______Home Phone: ______
Race: ______Sex:______Marital Status:______
Diagnoses:
Axis I ______GAF:______Medications:
Axis II ______
Axis III ______
Axis IV ______
Allergies: ______
Emergency Family Contact: ______
Alternate Contact: ______
Primary Physician: ______Phone: ______
Family Email Contact: ______
Approved list of persons with whom consumer can be left: ______
Professional Rehabilitation Consultants
Consent for Release of Information
Name: ______Record #: ______
I, the above named, hereby authorize Professional Rehabilitation Consultants to release or receive all necessary information for my plan of care and services to ______.
This release may include referrals, reason for referrals, psychiatric, psychological, social and medical information relevant to current functioning, current medications, history of medication, school reports or other information relevant to my care.
This information will be used to support the need for services and to facilitate and coordinate delivery of services in the best interest of the consumer. It is not available for secondary re-release or for the purposes of any legal action. Documentation will only be release under subpoena in the event of legal action.
I understand that the contents of the information for release are confidential and not available for secondary re-release from PRC. I acknowledge that I or my guardian gives consent for this two way release of information for a period of three years. I also acknowledge that I may revoke this consent at any time for future releases and that any revocation must be in writing.
______
Consumer Signature/Guardian/ DateWitness/ Date
Professional Rehabilitation Consultants
Policy on Transportation
Name: ______Record #: ______
Transportation of consumers is only allowed for working on community goals. During the school day if the consumer is a public school student the school system is to provide services, unless the direct care plan has specific community goals which must be completed immediately following school and can only be completed by the staff if the consumer is picked up from school. Staff is not to transport consumers for staff errands or trips, but rather only for community goals for the consumer.
I have read and received the policy on transportation, had it explained in language I understand, and certify that I understand the policy.
______
Consumer Signature/Guardian/ DateWitness/ Date
Professional Rehabilitation Consultants
Policy on Search and Seizure
Name: ______Record #: ______
No consumer shall be subjected to search of person or environment without just cause that the consumer may be in possession of items of an illegal nature (illegal drugs, unregistered handguns, etc) or items which may be used for physical violence towards self or others. In the event the direct care staff believes there is just cause for search and then seizure of any restricted items, the direct care staff shall file an incident report as soon as possible following the search and seizure. The incident report will follow policy for reporting incidents to QP and filing report within 24 hours. Any seized items will be placed in the possession of the QP and the disposition of such objects shall follow legal remedies if an illegal item or shall be disposed with the instructions of the legal guardian. Where the consumer is his/her own guardian, the QP shall confer with the CEO clinical services to determine appropriate disposition of items.
I have read and received the policy on search and seizure, had it explained to me in language I understand, and certify that I understand the policy.
______
Consumer Signature/Guardian/ DateWitness/ Date
Professional Rehabilitation Consultants
Policy on Restrictive Interventions
Name: ______Record #: ______
"Restrictive intervention" means an intervention procedure which presents a risk of mental or physical harm to the consumer and, therefore, requires additional safeguards. Such interventions include the emergency use of NCI interventions as approved by the State of North Carolina, by a trained consultant, to interrupt self-injurious, other injurious or property injurious behaviors.
I have read and received the policy on planned restrictive interventions, had it explained to me in language I understand, and certify that I understand the policy.
______
Consumer Signature/Guardian/ DateWitness/ Date
This consent is valid for 12 months from date of signature and must be re-evaluated before submission. Expires:______
Professional Rehabilitation Consultants
Fee for Services Agreement
Consumer Name : ______
Record #: ______
Medicaid/Medicare Consumer Certification: I, the undersigned, hereby authorize Professional Rehabilitation Consultants to release information and request payment for services rendered through CAP programs, or any other program where services are rendered.
Assignment of Insurance Benefits: I, the undersigned, hereby authorize direct payment of benefits not to exceed the regular charges of similar services to Professional Rehabilitation Consultants by any relevant third party where PRC is an approved service provider.
Authorization for Release of Medical Information: I, the undersigned, hereby authorize Professional Rehabilitation consultants to release any medical or service information required for processing claims for reimbursement of payments for services rendered by PRC.
I have received the policy on fee for services, had it explained to me in language I understand, and certify I understand the policy. ______
Consumer Signature/Guardian/ DateWitness/ Date
Professional Rehabilitation Consultants
Consents
Consumer Name : ______Record #: ______
Consent to Participate in Recreational Activities
It is understood that PRC services, staff, county, and area program will be held harmless in the event of accident or injury to the
consumer while participating in supervised community and agency activities and events.
______
Consumer Signature/Guardian/ DateWitness/ Date
Consent to Seek Emergency Medical Care
I authorize for any staff members or representatives of PRC to obtain emergency medical care for ______. It is understood that PRC services, staff, county and area program will be held harmless in the event of accident or injury to the consumer while obtaining emergency medical care.
______
Consumer Signature/Guardian/ DateWitness/ Date
Consent to be Transported
It is understood that PRC services, staff, county and area program will be held harmless in the event of accident or injury to the
consumer while being transported for any supervised community and agency activities and events.
______
Consumer Signature/Guardian/ DateWitness/ Date
Professional Rehabilitation Consultants
Request for and Consent to Treatment Services
Consumer Name : ______Record #: ______
I am requesting services from Professional Rehabilitation Consultants for ______
If accepted into services, consent is hereby given to the treatment services recommended in the current treatment plan and may be revised as needed through plan updates. The plan updates will always be with my consent. This consent is fully understood
______
Consumer Signature/Guardian/ DateWitness/ Date
Policy on Termination of Services
I, ______understand that my consent for treatment services from Professional Rehabilitation Consultants is voluntary and that I am free to terminate the services at any time.
______
Consumer Signature/Guardian/ DateWitness/ Date
Professional Rehabilitation Consultants
Grievance Procedures
Consumer Name : ______Record #:______
At PRC consumer satisfaction is our primary goal. If during the course of provision of services the consumer or legal guardian is dissatisfied with any aspect of service, we request they follow the outlined grievance procedures:
- Speak to the direct staff with which there is a concern.
- If this is unresolved, please contact the QP for that staff person.
- If this is unresolved, please contact the CEO of clinical services.
- If this is unresolved, please contact the LME in the consumer’s county to file a complaint following their procedures.
At any time the consumer has the right to contact the Governor’s Advocacy Council for Persons with Disabilities via telephone at 800-821-6922 or via US mail at: GACPD
1314 Mail Service Center
Raleigh, NC 27699-1314
I have received the policy on grievance procedures, had it explained to me in language I understand, and certify that I understand the policy.
______
Consumer Signature/Guardian/ DateWitness/ Date
PRC Consumer Intake 1
February 2010