new priorities family services 1655 sw highland avenue, #3 ... · 1655 sw highland ave suite 3,...

Individual's Name:___________________________________________ Email:________________________________Address:_____________________________________________________ City/Zip:______________________________Home:_________________________ Cell:__________________________Work:________________________________DOB:__________________ Age:______ Sex:______ Social Security Number:_____________________________Employer:____________________________________________________Occupation:__________________________Emergency Contact:_________________________ Relationship: ____________Phone#___________________Marital Status: Married___ Widowed___Divorced___Single___Military Status: Served___ Serving___ None___ Referred By: ___Qwest Directory___ Valley Directory ___Therapist ___Friend ___OtherResponsible Party/Parent/Legal Guardian/Primary Care Giver:Name: _______________________________ DOB: _____________ Sex:_____SSN:___________________________Employer: ___________________________ Occupation:________________ Work#_________________________Address: _____________________________City/Zip:____________________ Home/cell#____________________ Spouse/Significant Other Information:Name: _______________________________ DOB: _____________ Sex:_____ SSN:___________________________Employer:___________________________ Occupation:________________ Work#_________________________Home/Cell#_________________________

Family Physician: ______________________ Location:______________________ Phone#__________________Family Dentist: ________________________ Location:______________________ Phone#__________________

Insurance Information:Health Insurance Plan:__________________________________ Policy Holder:___________________________ID#______________________________EAP/Secondary Insurance Plan:_________________________ Policy Holder:___________________________ID#______________________________ Authorization/Certification#:____________________________________

I authorize New Priorities Family Services to provide information to my insurance carrier,including diagnosis, services rendered, and progress, as needed to process my insuranceclaim. I also authorize payment of mental health therapy/counseling benefits to New PrioritiesFamily Services for services provided.

_____________________________________________________________________________________________________Signature (Insured or Authorized Person) Date

N E W P R I O R I T I E S F A M I L Y S E R V I C E S

Providing Outpatient Mental Health, Drug & Alcohol Treatment and DUII Services

Individual Information FormIndividual Information

NPFS

Rev. 07/2020


NPFSProviding Outpatient Mental Health, Drug & Alcohol Treatment and DUII Services

Confidential Personal Data Intake Form

Date:______________ Name: _______________________________ DOB:__________________ Age:_________

Major issue you want to discuss:_______________________________________________________________

In your own words, list your strong points:______________________________________________________________________________________________________________________________________________________

What is your goal for counseling/What are you willing to do to obtain this goal?_______________________________________________________________________________________________________________

Please make any comments that you feel are important to this counseling process:__________________________________________________________________________________________________________

Problem Check List:

_____ _____ Loss of Appetite_____ _____ Poor sleep/sleep too much_____ _____ Not performing in school or work_____ _____ Work too hard/over ambitious_____ _____ Feel people are down on me_____ _____ Unable to have a good time _____ _____ Communication problems/spouse_____ _____ Sex problems _____ _____ Feel depressed _____ _____ Emotions/feelings are numb_____ _____ Worry a lot_____ _____ Don't enjoy any activities _____ _____ Lack of goals _____ _____ Afraid of being on own_____ _____ Feel tense/anxious_____ _____ Unable to be intimate_____ _____ Other:____________________________

_____ _____ Eat too much_____ _____ Nightmares _____ _____ Not doing household chores_____ _____ Can't make friends _____ _____ Shy with people_____ _____ Feel rejected _____ _____ Communication problems/child_____ _____ Financial problems _____ _____ Feel inferior to others_____ _____ Lack self-confidence _____ _____ Can't make decisions_____ _____ Forgetfulness_____ _____ Unable to cope_____ _____ Suicidal thoughts _____ _____ Feel angry/physically_____ _____ Crying spells

Never Sometimes/Often Never Sometimes/Often

Rev. 07/2020



OHP Therapy Attendance Policy

In order for us to ensure the best possible results from therapy, you must activelyparticipate in the program developed for you by attending all scheduled sessions.

Appointment Cancellation

We realize there may be circumstances that require you to change your scheduledappointment. When these situations occur, please notify your therapist 24 hours prior toyour scheduled appointment change so we may accommodate others waiting fortherapy and to avoid cancellation fee.

Appointment No Show

Our Therapists have set aside a specific time to provide your therapy. When you do notcall to cancel or do not show for your appointment, this is time the therapist could beproviding therapy to someone else. We realize that emergencies do occur, please callright away to make arrangements with your therapist.

Repeated Cancellations or No Shows

Cancellations or no shows will be documented in your chart. After 3 cancellations and/or2 no shows we will conclude your services. This shows the therapist, agency, andinsurance company this may not be the time for you to engage in therapy.

Acknowledgement

I have read the attendance policy and acknowledge my understanding of activeparticipation for scheduled therapy sessions.

________________________________________________________________________________________________Client Signature Date

____________________________________________________________________________________________________________________ Counselor Signature Date

Rev. 07/2020



No Show Payment Agreement

I, _______________________________________ agree to pay $45.00 for any individual session, group,or other treatment activity that I or my son/daughter has agreed to attend and misseswithout giving notice, unless a crisis occurs beyond your control we very much understandunforeseen circumstances arise. If you call and staff in unable to take your call, leaving amessage is satisfactory.

This agreement does not apply to individuals on OHP insurance coverage; however, failureto contact our office resulting in an unexcused absence may initiate an extended programcompletion date, a change in the level of care or possible termination of services.

___________________________________________________________________________________________________Client Signature Date

___________________________________________________________________________________________________Signature of Parent/Legal Guardian Date

___________________________________________________________________________________________________NPFS Counselor (Name/Credentials) Date

___________________________________________________________________________________________________NPFS Director, Karen Ludwig MS, NCC, MAC, LPC Date

Date Counselor Signature Client Signature

Cancellation #1 ____________ _____________________________ _____________________________

Cancellation #2 ____________ _____________________________ _____________________________

Cancellation #3 ____________ _____________________________ _____________________________

No Show #1 ____________ _____________________________ _____________________________

No Show #2 ____________ _____________________________ _____________________________

Cancellation/No Show Documentation Log

Rev. 07/2020



Tobacco/Smoke-Free Property

NPFS is a federal/State funded program and we have to abide by their rules andregulations. No smoking is permitted on the property at any time.

We have had several incidents with the fire department response team in the last coupleyears and in order to avoid making emergency calls to the Redmond Fire Department dueto cigarettes being tossed into the bark chips the Redmond Fire Marshall has advised usto create a Smoke-Free Property.

A building fire is an increasing concern and liability which could adversely affect NPFS,clients and families and/or potentially cause a closure of the business in the event of a fire.

Highland Plaza / New Priorities Family Services is a SMOKE-FREE PROPERTY

Verbal Warning: If you are caught smoking on the property you will be asked to leave theproperty but may return back to NPFS after you are done smoking as long as it is non-disruptive to your scheduled appointment, time, counselor, other clients and families.

Warning: If you continue to smoke on the property after your verbal warning you will beasked to leave the property and you may not return until your next scheduledappointment and/or group.

Final Warning: You may be asked to seek services elsewhere.

New Priorities Family Services appreciates your understanding and cooperation in this matter.

Sincerely,

Karen Ludwig, Director

By signing below, you acknowledge that you understand and agree to comply with theSmoke-Free Policy.

__________________________________________________________________________________________________Client Print Name Signature Date

Rev. 07/2020



Contract For Psychotherapy Services

Full payment or your Co-pay is expected at this time of service. Payment plans can bearranged with the billing department. Self-pay fees and/or co-pay assistance may beavailable depending on your income and circumstances. In the even you may needassistance discuss your circumstances with your counselor. ____________(Initial)

Payment Options: Currently we can accept cash, checks, Visa/MC debit cards, and HSAcards. Be aware that there will be a charge of $45.00 for returned checks due toinsufficient funds. If you have any questions, please check with us prior to your session.

Insurance: As a courtesy, we submit an insurance claim to your insurance company forreimbursement. Please make sure you understand your Insurance Policy and the servicesit provides and covers. Many Insurance companies/plans require preauthorization forservices you are responsible for contacting your insurance to ensure services will becovered and provide us with any necessary authorization/certification numbers, expirationdates, or visit limits given to you by your insurance.

You will be financially responsible should your insurance deny any claims for services rendered at NPFS.

Appointments: Your appointment time is a commitment between you and NPFS to provideyou the services needed. This time is YOURS. therefore, we ask that you give a 24-hournotice of cancellation. We realize that emergencies do occur, please call right away tomake arrangements with your therapist or you will be charged a cancellation fee of $40.00for No Call/No Show (OHP exempt).

I have read and understand the contract obligation stated above

__________________________________________________________________________________________Client Print Name Signature Date

Cost of Services Provided

Initial Evaluation/Consultation $200Individual Therapy (30 min.-1hr) $92-$184Family Therapy $150Group Therapy $60OHP Individuals - Cost of services set by State

Alcohol/Drug Assessment $200Individual Session (1-4 units) $46-$184Family Therapy $150Group Therapy $60UA Collection Fee $20

Chemical DependencyMental Health

Rev. 07/2020



Acknowledgement of Receipt of Notice of Privacy Practices &

Consent for use and Disclosure of Health Information

Reporting suspected child abuseReporting imminent danger to client or othersYou request my appearance in court to testify on your behalfLicense consultation or supervisionDefense of claims brought by client against licenseeIf the client is a minor, legal guardian may have a right to information

By law, all information obtained in the course of psychotherapy shall remain confidential, andwill not be released without your written consent, except under the following conditions:

I understand that New Priorities Family Services will use and disclose health information aboutme. I understand that my health information may include information both created andreceived by this provider; records may be in the form of written, electronic or spoken words,and may include information about my health history, health status, symptoms, examinations,test results, diagnosis, treatment, procedures, prescription and other similar types of health-related information.

I understand that I have the right to receive and review a written description of how NewPriorities Family Services will handle health information about me. This written description isknown as a Notice of Privacy Practices and describes the uses and disclosure of healthinformation made and the information practices followed by the employees, staff, and otheroffice personnel of New Priorities Family Services and my rights regarding my healthinformation.

I understand that the notice of Privacy Practices may be revised from time to time, and I amentitled to receive a copy of any revised Notice of Practices. I also understand that a copy orsummary of the most current version of the Notice of Privacy Practices will be posted in thewaiting area. I understand that I have the right to ask that some or all of my health informationnot be used or disclosed in the manner described in the Notice of Privacy Practices, and Iunderstand that New Priorities Family Services is not required by law to agree to such request.

By Signing below I agree that I have reviewed and understand the information above andthat I have received a copy of the Notice of Privacy Practices.

__________________________________________________________________________________________Client Print Name Signature Date

(Turn page over)

Rev. 07/2020



Declaration of Treatment

Please INITIAL on the following to indicate a Yes or No answer

Do you have a Declaration for Mental Health Treatment and/or Advance Directive?

Would you like help completing a Declaration for Mental Health Treatment?

Would you like an info packet about Declaration for Mental Health Treatment?

Are you a registered voter?

Would you like a voter's registration card?

_____ _____

_____ _____

_____ _____

_____ _____

_____ _____

Yes No

_____________________________________________________________________________________________________Client/Representative Name Signature Date

__________________________________________________________________________________________________________________________Parent/Guardian Signature Date

Visit these websites for more information on Declaration of Mental Health Directive and Advanced Directive

www.Oregon.gov/oha/amh/pages/services/planning.aspxwww.Oregon.gov/DCBS/insurance/shiba/Documents/advancedirectiveform.pdf

I attempted to obtain a written acknowledgement of receipt of our Notice of Privacy Practice,but acknowledgement could not be obtained because: Emergency situation prevented usfrom obtaining acknowledgement _______Communication barriers prevented us fromobtaining acknowledgment _______ Individual refused to sign______ other (pleasespecify)____________________________________________________________________________________________

For Office Use Only

Rev. 07/2020



Notice of Privacy Practices

You can ask to limit how we use or share your information. You must ask in writing. We can agree iflaw allows.You can ask us to contact you in a certain way or in a certain place. We will follow any realisticrequest.In most cases, you can look at or get copies of your records. You must ask in writing. You may haveto pay for the copies. Please contact us for the form.You can ask to amend health information in your medical or billing records. This must be in writing.We may not agree to these changes in certain situations. You can ask us what health information we shared about you after April 14, 2003. You must ask inwriting. This list will not have information we shared for treatment, payment, or health careoperations that you gave permission to share.You can usually take back your written permission if you ask us in writing. We can't take back anyinformation we have already given.

NPFs Program Director; Karen Ludwig (541) 923-2654 Fax (541)548-8099

Deschutes County Risk Manager (541) 330-4631 Fax (541) 617-4704

Secretary of the Department of Health & Human Services Region 10 HHS

What is Protected?Protected Health Information (PHI), which means any medical information with your name on it. Your Records: Are kept in a chart with your name on it. They can be stored in a computer. Tell whattreatment and test you have had and what health care choices have been made. Protecting your privacy: By law, we must keep your medical information private except in somesituations. We must give you a copy of these rules. All Deschutes County Health Service Employeesand volunteers must follow these rules. When we need your written permission: To share some information such as: Mental Health, Alcoholand Drug Abuse Treatment, HIV/AIDS testing or treatment and genetic testing information. How we may share you PHI Medical Treatment: Information for payment. Your medical care.Appointment reminders. To tell you about services or treatment. DCHS Business associates, Labs,Pharmacies, and Interpreters. Special situations: to talk to people who help for your care,Workers compensation. To schedule an interpreter for you. In the event of a disease, To reportbirths or deaths, Healthcare emergency. Eminent threat to self or others.Legal purposes: For specific court request such as subpoenas. To report suspected abuse, neglector domestic violence. For investigations or audits. To jails or prisons. For national security or toprotect the President. Privacy Complaints: We care about your concerns! If you do not agree with how we used ordisclosed information about you, you may file a complaint. You will not be punished and your carewill not be affected if you file a complaint.To file a privacy complaint, please contact:

1655 SW Highland Ave Suite 3, Redmond, OR, 97756

1300 NW Wall St. Suite 200, Bend, OR, 97701

Voice phone (206) 615-2290 TDD (206) 615-2296 Fax (206) 615-2297

What are your privacy rights?

Rev. 07/2020



Grievance Policy and Procedures

Initiate a frank discussion between themselves and their clinical regarding individual concerns.A grievance shall be put in writing and inserted in the individual's file.If issue cannot be resolved the grievance is given to the NPFS Director/Supervisor who "willtake action" within 72 hours. An investigation of any grievance "will be completed" within 30 calendar days. During this time,the NPFS directors will receive and process the grievance and document any action taken on asubstantiated grievance and document receipt, investigation and action taken in response tothe grievance.

State of Oregon Health Authority 503-945-5772Disability Rights Oregon 503-243-2081Pacific Source Grievance and Appeals 1-888-863-3637The Governor's Advocacy Office 503-945-6904

NPFS staff will encourage and facilitate resolution of the grievance at the lowest possible level.

To file a grievance an individual is to follow procedures as listed in steps below:

Expedited Grievances: In circumstances where the matter of the grievance is likely to causeharm to the individual before grievance procedures are completed, the individual or guardianof the individual may request an expedited review. The program director must review andrespond in writing to the grievance within 48 hours of receipt of grievance. The writtenresponse must include information about the appeal process. If an individual does not feel NPFS is handling the grievance, the following agencies may becontacted:

Grievance AppealsIndividuals and legal guardians, have the right to appeal, entry, transfer, and grievancedecisions if they are not satisfied with the decision within ten working days of the date of NewPriorities Family Service's response to the grievance or notification of denial for services. Theappeal must be submitted to the CMHP Director in the county where the provider is located orto the Division as applicable.The CMHP Director of Division must provide a written response within ten working days of thereceipt of the appeal. If the individual or guardian is not satisfied with the appeal decision. he orshe may file a second appeal in writing within ten days of the date of the written response tothe director.

I have read and reviewed a copy of this document

______________________________________________________________________________________________________Client Print Name Signature Date

Rev. 07/2020

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Authorization for Release of Information

To our clients: We can help better if we are able to work with other agencies that know youand your family. By signing this form, you are giving permission for these organizationsand/or individuals to share information about you/your situation .

Client Name:_____________________________________________DOB:_________________(MM/DD/YYYY)

I, _____________________________________________ authorize the following individual and/or agency(Client or Parent/Guardian Name)

_______________________________________________________________________ to provide, disclose and(Name of Individual and/or Agency)

exchange the following information to New Priorities Family Services (NPFS) and from NPFS.

Including records of: Please Circle Yes/No ( INITIAL after all "Yes" answers to be valid)

Family HistoryEmployment/UnemploymentMental Health ServicesUrinalysis Testing (UA)Other (Please Describe)

Record Type

________________________________

Yes / No

Y / NY / NY / NY / NY / N

Initial

______________________________

Alcohol/Drug TreatmentEducational ReportsMedical/Psychiatric TreatmentCriminal HistoryRevoked

Record Type Yes / No

Y / NY / NY / NY / NY / N

Initial

______________________________

________________________________________________________________________________________________Client Signature Date

____________________________________________________________________________________________________________________Parent/Guardian Signature Date

____________________________________________________________________________________________________________________ Witness Signature Date

Alcohol/Drug, Mental Health, Medical Records, and UA's may include all aspect of diagnosis, treatment, andprognosis. Educational, Employment, ad Criminal records may include behavioral, progress, and status reports.I agree that agencies and/or individuals listed above may share and exchange information about mycircumstances including, but not limited to other purposes as specified.I understand that information about my substance use disorder records and/or Mental Health records are/isprotected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records,42 CFR Part 2, and the Health Insurance Portability and Accountability Act (HIPPA) of 1996, 45 CFR pts 160 & 164,and cannot be disclosed without my written consent unless otherwise provided for by the regulations. Iunderstand that I may revoke this authorization at any time except to the extent that action has been taken inreliance on it and/or will not affect any information that was released prior to the cancellation. Unless I revoke myconsent earlier, this consent will expire automatically one year from the date which this consent has been signed.

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Rev. 07/2020



I understand that I will be denied services if I refuse to consent to a disclosure forpurposes of treatment, payment, and/or health operations, if permitted by state law. Iwill not be denied services if I refuse to consent to a disclosure for other purposes.

I have been offered/provided a copy of this form. Dated:__________________

________________________________________________________________________________________________Client or Parent/Guardian Name Signature of Client or Parent/Guardian

_________________________________________________________Description of signer (Self/Client or Parent/Guardian)

Or

I do not give permission for giving records. Date:___________________

________________________________________________________________________________________________Client or Parent/Guardian Name Signature of Client or Parent/Guardian

_________________________________________________________Description of signer (Self/Client or Parent/Guardian)

Rev. 07/2020



COVID-19 Liability Release Waiver

Symptoms of Covid-19 Include:FeverShotness of breathLoss of sense of taste or smellDry coughRunny noseSore throatDifficulty breathing

Due to the 2019-2020 outbreak of the Coronavirus (COVID-19) NPFS is taking extra precautionswith the care of every client to include health screenings, enhance sanitation/disinfectingprocedures in accordance with the Oregon Executive Orders, Oregon Health Authority, and allother local guidance.

I _______________________________________________, knowingly and willingly consent to have servicesprovided by NPFS during the existing state of emergency due to the COVID-19 Pandemic. Iunderstand the COVID-19 virus has a long incubation period during which carriers of the virus maynot show symptoms and still be highly contagious. It is impossible to determine who has it andwho does not given the current limits in virus testing.

I agree to the following (initial):_____ I understand the above symptoms and affirm that I as well as all household members do notcurrently have, nor have experienced any of the symptoms listed above, WITHIN THE LAST 14DAYS._____ I affirm that I as well as all household members have not been diagnosed with COVID-19WITHIN THE LAST 30 DAYS. _____ I affirm that I, as well as all household members have not knowingly been exposed to anyonediagnosed with COVID-19 WITHIN THE LAST 30 DAYS. _____ I affirm that I, as well as all household members have not traveled outside the United Statesor to any City considered to be a "hot spot" for COVID-19 infections WITHIN THE LAST 30 DAYS. _____ I understand that NPFS cannot be held liable for any exposure due to the COVID-19 viruscaused by misinformation on this form or health history provided by each client._____ I have been made aware of the CDC and OHA guidelines that under the current pandemicthat close personal contact is not recommended. Services provided by NPFS will follow NPFSprotocols. (Posted and a copy available upon request). By signing below, I understand and agree to each statement above and release NPFS and NPFSstaff from any and all liability for the unintentional exposure or harm due to COVID-19, NPFS andall NPFS employees agree to abide by these standards and affirm the same.

___________________________________________________________________________________________________________Client Print Name Client Signature Date

Rev. 07/2020