Referral to Charles Webster Potter Place
1. Please have the C.W. Potter Place referral form filled out by a prospective member's Doctor, Psychiatrist, Therapist, Case Manager, Mass Rehab worker, etc. We encourage the prospective member to be involved in the writing of the referral and to have input into what information is included in it.
2. Upon completion, the referral gets mailed to:
Charles Webster Potter Place
15 Vernon Street
Waltham, MA 02453
Attention: Program Director
Fax to: (781) 891-3812
3. When we receive the referral we will call the prospective member to set up a Guest Day. Guest Days are typically held on Tuesdays, Wednesdays, and Thursdays from 9 a.m. -2 p.m. This gives the prospective member an opportunity to be involved in the prevocational work-ordered day by spending time in both work areas, along with gaining more information on our vocational and educational supports. The member would also use this as an opportunity to ask questions and fill out some necessary paperwork.
4. If you have any questions or concerns regarding this process, we encourage you to call the Program Director at (781) 894-5302.
15 Vernon Street, Waltham, MA 02453
Tel: 781.894.5302
Fax: 781.8913812
E-mail:
Referral Form
C. W. Potter Place Clubhouse Services
A Program of the Edinburg Center
Date: Click here to enter text.
Member Name: Click here to enter text.
Date of Birth: Click here to enter text.
Current Address: Click here to enter text. Permanent Address: Click here to enter text.
Phone Number: Click here to enter text.
Referred By: Click here to enter text.
Referring Agency: Click here to enter text. Phone: Click here to enter text.
What goals would the member like to work on at Potter Place:
☐ Employment
☐ Education
☐ Housing
☐ Community Linkage
☐ Health and Wellness
☐ Life Skills
☐ Social/Recreation
☐ Transportation
Please forward the completed referral to:
C.W. Potter Place
Attention: Program Director Phone: 781 894.5302
15 Vernon Street Fax: 781 891.3812
Waltham, MA 02453 E-mail:
______
For Administration Office Use Only
Date Received: Click here to enter text. Date Entered: Click here to enter text.
Primary Language: Click here to enter text.
Marital Status: Click here to enter text.
Gender: Click here to enter text. Social Security #: Click here to enter text.
PROVIDERS:
Therapist: Click here to enter text. Phone: Click here to enter text.
DMH Case Manager: Click here to enter text. Phone: Click here to enter text.
CBFS Worker: Click here to enter text. Phone: Click here to enter text.
House Manager: Click here to enter text. Phone: Click here to enter text.
Psychiatrist: Click here to enter text. Phone: Click here to enter text.
Mass. Rehab.: Click here to enter text. Phone: Click here to enter text.
Legal Guardian: Click here to enter text. Phone: Click here to enter text.
Address: Click here to enter text.
______
Rep. Payee: Click here to enter text. Phone: Click here to enter text.
Address: Click here to enter text.
______
Other: Click here to enter text. Phone: Click here to enter text.
DSMIV DIAGNOSIS:
Axis I Click here to enter text.
Axis II Click here to enter text.
Axis III Click here to enter text.
Axis IV Click here to enter text.
Axis V Click here to enter text.
Date of Most Recent Appointment with Psychiatrist/Therapist: Click here to enter text.
Signs/Symptoms of Decompensation: Click here to enter text.
______
MEDICATION:
Type Click here to enter text. Dosage Click here to enter text. Frequency Click here to enter text.
HISTORY:
Family: (significant family members and relevant areas, i.e. mental illness, alcohol/drug abuse, sexual and/or physical abuse)
Click here to enter text.
Psychiatric: (please give a description of when this person began experiencing difficulties and treatment that has occurred)
Click here to enter text.
History of Suicidal and/or Assaultive Behavior:
Click here to enter text.
Does the person have any legal action pending? If so, please explain. (I.e. probation officer, etc.):
Click here to enter text.
History of Alcohol or Drug Abuse:
Click here to enter text.
Allergies and/or Medical Conditions:
Click here to enter text.
Previous Hospitalizations: (please begin with most recent)
Hospital Dates Precipitant
1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
4.Click here to enter text.
5. Click here to enter text.
Previous Day Program Placements: (List most recent first)
Type/Name Dates/Duration Reason for Leaving
1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
4. Click here to enter text.
Masshealth Policy # (if applicable):
Click here to enter text.
PERSON TO NOTIFY IN CASE OF EMERGENCY:
Name: Click here to enter text. Relationship: Click here to enter text.
Address: Click here to enter text.
Phone: Click here to enter text.
FINANCIAL/INCOME:
Source or Income: (please check all that apply):
☐SSI ☐SSDI ☐Family ☐Pension ☐Wages ☐Other
If wages or other, please explain: Click here to enter text.
HOUSING: (please describe current housing situation)
Click here to enter text.
EDUCATION and EMPLOYMENT HISTORY
Last Grade Completed: Click here to enter text. Degree/Cert. Year: Click here to enter text.
Name and location of school: Click here to enter text.
Special Training: Click here to enter text.
Where: Click here to enter text. Year: Click here to enter text.
Educational Goals: Click here to enter text.
Employer Type of Work Dates of Employment Reason for Leaving
(List most recent job first; include volunteer work)
1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
4. Click here to enter text.
5. Click here to enter text.
Special Training: Click here to enter text.
Where: Click here to enter text. Year: Click here to enter text.
Employment Goals: Click here to enter text.
Other Relevant Information: Click here to enter text.
Consumer Signature: ______Date: Click here to enter text.
Signature: ______Date: Click here to enter text.
Title: Click here to enter text.
The Edinburg Center, Inc.
1040 Waltham Street
Lexington, MA 02421
781-862-3600
For Office Use Only
Accepted: ☐ Declined: ☐
Revoked: ☐
Date: Click here to enter text.
AUTHORIZATION FOR DISCLOSURE OR EXCHANGE OF CONFIDENTIAL INFORMATION
Client Name: Click here to enter text. Date of Birth: Click here to enter text. Ct #: Click here to enter text.
I authorize The Edinburg Center to: (check one, or both) ☐release / ☐obtain protected health information
to/from: Click here to enter text.
Agency and/or Person: Click here to enter text.
Street Address: Click here to enter text.
City/Town: Click here to enter text.
State: Click here to enter text.
Zip: Click here to enter text.
______
☐Check here if you are allowing an on-going “two-way exchange” of Confidential Health Information between The Edinburg Center and the party named directly above.
______
Method of Release (Check all that apply.)
☐Telephone/Verbal (tel #.)
☐Other (please specify)
☐Fax #
☐U. S. mail/in person
______
The purpose(s) of this Authorization is (are)
☐Coordination of Care
☐Quality of Care Review
☐At the request of the client
☐Treatment or service planning
☒Response to gov’t agency request
☐Facilitate billing
☐Referral
☐Response to court order
☐Other: Click here to enter text.
______
Information to be released or obtained includes:
☐Entire Record, OR the following (check all that apply):
☐Admission assessments
☐Progress notes
☐Physical exam results
☐Payment/billing records
☐Mental health treatment history
☐Psychological test results
☐Treatment plan
☐Individual Service Plan
☐Referral information
☐History and Physical
☐Psychiatric evaluation/mental status
☐Discharge summary
☐Medical & specialty consultations
☐School records
☐Other: Click here to enter text.
______
Specially Authorized Releases of Information (please check all that apply):
☐To the extent that my record contains information pertaining to the identity, diagnosis, prognosis or treatment for alcohol or drug abuse maintained by a federally-assisted alcohol or drug abuse program, I specifically authorize release of such information.
☐To the extent that my record contains information regarding AIDS, ARC or HIV including, for example, a test for the presence of HIV antibodies or antigens, regardless of whether (i) this test is ordered, performed, or reported and (ii) the test results are positive or negative, I specifically authorize release of such information.
☐To the extent that my record contains information regarding the results of a genetic test, I specifically authorize release of such information.
☐All health information about me as described in the preceding checkboxes, excluding the following:
Click here to enter text.
☐Other specific health information including only: Click here to enter text.
Note: Describe the health information to be excluded or included in a specific and meaningful fashion.
______
Unless otherwise revoked, this Authorization will expire on Click here to enter text.
(Specify a date, or an event, such as the termination of services from The Edinburg Center.)
IMPORTANT INFORMATION ABOUT THE RELEASE OF YOUR HEALTH INFORMATION
I understand that Health Information includes information collected from me or created by The Edinburg Center, or information received by The Edinburg Center from another provider, a health plan, my employer or a health care clearinghouse. Health information may relate to my past, present or future physical or mental health or condition, the provision of my care, or payment for my services.
I understand that The Edinburg Center cannot guarantee that the Recipient will not re-disclose my health information to anyone else. The Recipient may not be subject to federal laws governing privacy of health information. However, if the disclosure consists of treatment information about a client in a federally-assisted alcohol or drug abuse program, the Recipient is prohibited under federal law from making any further disclosure of such information unless specifically permitted by written consent of the Client or as otherwise permitted under federal law governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR, Part 2).
I understand that I may revoke this Authorization in writing at any time, except that the revocation will not have any effect on disclosures made as permitted by this Authorization before written notice of revocation is received. I further understand that that I must provide any notice of revocation in writing to the Privacy Officer at The Edinburg Center. The address of the HIPAA Privacy Officer is The Edinburg Center, 1040 Waltham Street, Lexington, MA, 02421.
I understand that I may refuse to accept this Authorization and that my refusal will not affect my ability to obtain services from The Edinburg Center, except (1) if I am receiving research-related treatment or (2) receiving health care solely for the purpose of creating information for disclosure to a third party, or 3) if my refusal may limit The Center’s ability to provide safe and effective care. If any of these exceptions apply, my refusal may result in my not obtaining services from The Center.
______
Choose one signature box below:
☐By signing directly below, I am indicating that I have read the “Important Information” section above, and that
I UNDERSTAND AND ACCEPT the terms of this Authorization. I am also verifying that I have had an opportunity to question or otherwise discuss the use or disclosure of my health information with my clinician or another knowledgeable staff person.
Signature of Client: ______Date: ______
Signature of Parent or Legal Guardian: ______Date: ______
Relationship, if not client: ______
Print Name: ______
OR
☐By signing directly below, I am indicating that I DO NOT accept the terms of this authorization.
Signature of Client: ______Date: ______
Signature of Parent or Legal Guardian: ______Date: ______
Relationship, if not client: ______
Print Name: ______
______
When client is under 18 years of age or not competent to give consent, the signature of a
parent, guardian, health care agent (proxy) or other legal representative is required.
______
Instructions:
1. This form should be double sided so that the original is one page.
2. This form must be completed in full to be considered valid.
3. A copy of this authorization shall be considered as valid as the original.
4. Distribution of copies:
(1) Original to the appropriate client record;
(2) Copy to Individual or Personal Representative;
(3) Copy to person/facility/agency making request.
HIPAA-F-2 (4/14/03)
Commonwealth of Massachusetts
Department of Mental Health
Notice of Privacy Practices Acknowledgment Form
Name: DMH ID#: Click here to enter text.
Facility/Site/Program: Click here to enter text.
I have received a copy of the DMH Notice of Privacy Practices
Version: Click here to enter text. Effective Date: Click here to enter text.
Signature:______Date:______
Individual or Personal Representative with legal authority to make healthcare decisions
If signed by a Personal Representative:
Print Name______Role______
(Parent, guardian, etc.)
Witness:______Date:______
If the individual has a personal representative with legal authority to make health care decisions on the
individual's behalf, the notice must be given to and acknowledgment obtained from the personal
representative. If the individual or personal representative did not sign above, staff must document
when and how the notice was given to the individual, why the acknowledgment could not be obtained, and the efforts that were made to obtain it.
Notice of Privacy Practices given to the individual on the following date: Click here to enter text.
Reason Individual or Personal Representative did not sign this form:
☐Individual or Personal Representative chose not to sign
☐Individual or Personal Representative did not respond after more than one attempt
☐Email receipt verification
☐Other: Click here to enter text.
Good Faith Efforts: The following good faith efforts were made to obtain the individual or Personal
Representative's, if applicable, signature. Please document with detail (e.g., date(s), time(s), individuals
spoken to and outcome of attempts) the efforts that were made to obtain the signature. More than one
attempt must have been made.
☐Face to face presentation(s)
☐Telephone contact(s)
☐Mailing(s)
☐Other
Staff Signature:______Title______
Print Name: ______Date___________
This form must be retained for a period of at least six years in the appropriate record in accordance with the
DMH Privacy Handbook.
☐Face to face meeting
☐Mailing
☐Other