Client Registration/Demographics
Total Page：16
File Type：pdf, Size：1020Kb
P E R F E C T L Y I M P E R F E C T Client Registration/Demographics Client Name: _________________________ DOB: ____________SS #:_______________ Address: ______________________________ City/State/ZIP: _______________________ Home Phone____________________________ Cell: _______________________________ Work: ________________________________ OK to Contact Work? Y N E-mail Address: ______________________ Presenting Problem: _____________________ Occupation: _________________ Employer: ______________ Employment Status: _______ Emergency Contact Person: __________________________________________________ Relationship: _______________________________Phone:__________________________ Insurance Information: Primary Insurance Co.________________________ Provider Phone #_________________ Policy/ID #:________________________________ Group #:________________________ I certify that the information on this document is true and correct Client Signature: _______________________________ Date: _______________________ For clinical staff only: ICD 10 diagnosis ____________, ____________, ____________, ____________ P.O./phone number__________________________________________________ Program/Start date__________________________________________________ Staff Signature: _____________________________________ Date: _________ Assessment scheduled__ All document signed__ 1 □ or I acknowledge electronically P E R F E C T L Y I M P E R F E C T Authorization for Release/Exchange of Confidential Information I _______________________________________ authorize Perfectly Imperfect to: _____ release to: _____ obtain from: _____ exchange with: __________________________________________ __________________________________________ __________________________________________ __________________________________________ the following information pertaining to myself: _____ treatment summary _____ history/intake _____ diagnosis _____ psychological test results _____ dates of treatment attendance _____ other (specify) ______________________________ for the purpose of: _____ evaluation/assessment and/or coordinating treatment efforts _____ other (specify) ______________________________ This consent will automatically expire one (1) year after the date of my signature. I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released). Client Signature: Date: ______________ Staff Signature: Date: ________________________________________________________________________ I, hereby revoke the above consent effective, _________ for the following reasons: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Client Signature: Date: ______________ Staff Signature: Date: 2 □ or I acknowledge electronically P E R F E C T L Y I M P E R F E C T Client Rights and Responsibilities Rights as a Person Receiving Mental Health Services I, __________________________ have read these rights on the date of _________and have been informed of the following: 1. To receive a written description of your rights in English or Spanish when requesting services. 2. To receive appropriate treatment or therapy for your substance use, emotional or psychological problem. 3. To be fully informed about any proposed treatment or therapy, including its risks and consequences. 4. To a treatment plan to meet your special needs, within 30 days of the date you begin receiving services. 5. To participate in designing and updating your treatment plan. 6. To confidentiality (see notice of Privacy and Confidentiality). 7. To be treated with respect and dignity 8. To request information about names, location, phones, and languages for local agencies 9. To be free from use of seclusion or restraints 10.To receive age and culturally appropriate services 11. To understand available treatment options and alternatives 12. To refuse any proposed treatment 13. To receive care that does not discriminate against you (e.g. age, race, type of illness) 14. To make an advance directive that states your choices and preferences for mental health care 15. To file a grievance with your agency 16. To have family participate. 17. To change mental health care providers during the first 30 days, and sometimes more often 18. The right to access your records. You have the right to read your case record, treatment plan or any information the facility or agency has about you and to make copies of that information. Client Responsibilities Responsibilities of a Person Receiving Services at Perfectly Imperfect 1. Keep your scheduled appointments and let us know as soon as possible if you cannot keep one. 2. Be as honest and open as possible with your counselor. 3. Between sessions, think through the concerns you are addressing in counseling. 4. Follow through on treatment recommendations and complete your counseling homework assignments. 5. We ask that you end your work with us in a termination session, rather than not keeping your appointment. This way you can share and discuss with your counselor what was useful and what could have been improved. 6. If you feel that you might harm yourself or others, during business hours contact Perfectly Imperfectly, crises lines provided at intake or 911. After business hours call crises lines provided at intake or 911. I am aware my records will be shared with the Treatment Team for Supervision. ___________________________ ______________ Client Signature Date ___________________________ ______________ Staff Signature Date 3 □ or I acknowledge electronically P E R F E C T L Y I M P E R F E C T Financial Responsibility Policy Perfectly Imperfect LLC would like to thank you for choosing us to provide your counseling needs. The policies listed below have been approved by management with the goal of providing quality and professional service to our clients. Perfectly Imperfect LLC shall provide service regardless of race, color, creed, handicap, socioeconomic status, sexual orientation and religious beliefs. Bill Responsibility All patients or guarantors receiving services are financially responsible for the timely payment of all charges incurred. While Perfectly Imperfect LLC will file claims with the patient’s designated insurance company as a courtesy, the patients/guarantors shall ultimately be responsible for any outstanding balance not covered by insurance in accordance with the posted counseling fees presently in effect. Not all services are covered by all insurance companies. It shall be understood that by accepting and consenting to services, the patient is responsible for payment regardless of insurance coverage. Point of service Collections Payment for services is due upon services rendered. Non-emergency series may be deferred until necessary payment arrangements have been established. Clients unable to comply with Point-of- Service payment policy will be assisted in making necessary arrangements. If patients account is not paid in full or a satisfactory arrangement made within allowable time frames, Perfectly Imperfect LLC reserves the right to refer the account to an attorney or a collection agency. Payment Agreements Perfectly Imperfect LLC will make a reasonable effort to assist patients in meeting their financial obligations. Financial arrangement or payments shall be at the clinician’s discretion based on the amount due. Acceptance of Insurance Perfectly Imperfect accepts Self pay clients and Medicaid Centennial Full benefits, and Alternative Benefits Packages from Presbyterian, Blue Cross Blue Shield, United Behavioral Health Care, or Molina My signature below acknowledges that I have read or have been explained this Admission Information Form, I agree that I am financially responsible for all charges incurred that are not covered services of my health insurance company. Clients Signature/Responsible Party: ______________________________Date: ______ Staff Signature: _____________________________________ Date: _________ 4 □ or I acknowledge electronically P E R F E C T L Y I M P E R F E C T Client Grievance Procedure Perfectly Imperfect is dedicated to providing the highest quality of services to our clients. We believe to accomplish this; we must provide forums for our clients to give us feedback. The Perfectly Imperfect Procedure was developed to establish a method of addressing issues and/or concerns that cannot be resolved informally between you and agency staff. All client grievances will be investigated and resolved promptly in accordance with the New Mexico Counseling and therapy Practice Board. If you are upset about your program or anything that has happened to you at Perfectly Imperfect do the following. 1. Tell your counselor what is bothering you. They will do everything they can to resolve the issue with you. 2. If you are unable to solve your grievance with you counselor, you may meet with the Clinical Supervisor. 3. If the grievance cannot be resolved informally clients will submit their grievance in writing, and will meet with the Director of Operation. 4. The Director will respond to the client’s grievance within 7 days. 5. If a member of a Centennial Care Managed Care organization, is dissatisfied with outcomes, they have the right to file a grievance following the CC MCO process. 6. If a Medicaid fee-for-service recipient, they have the right to request a Fair Hearing: Fair Hearings Bureau P.O. Box 2348 Santa