form – Positive Growth Inc.

FORM TEST

Client Information (Complete)

1. Start
2. 2
3. 3
4. 4
5. 5
6. 6
7. 7
8. 8
9. 9
10. 10
11. 11
12. 12
13. 13
14. 14

EMERGENCY INFORMATION AND CONSENT FORM (optional)

EMERGENCY INFORMATION AND CONSENT

Name:

Record No: (optional)

Date:

Address:

Home PH:

Wk. PH:

City: (optional)

SS#: (optional)

State: (optional)

Zip Code: (optional)

Medicaid No:

Sex:

D.O.B.:

Medicare No:

Emergency Physician: (optional)

Insurance No: (optional)

Attending Physician: (optional)

Hospital Pref.: (optional)

Diagnosis: (optional)

Allergies: (optional)

Medications: (optional)

In Case of Emergency Contact or Call:

Guardian:

Contact # 1:

Contact # 2:

Contact # 3:

EMERGENCY CARE, CONSENT AND CONTACTS (optional)

In the case of a medical emergency while the client is participating in a program, the staff will provide first aid. In the event that the emergency room, hospitalization, or other appropriate medical or dental care is needed, appropriate transportation to the appropriate facility will be arranged. The parent/guardian/custodian (or designated contact person) will be contacted to meet the client at the facility. If the parent/guardian/custodian (or designated contact person) cannot be reached, the staff member may authorize the physician/dentist/facility to provide emergency treatment.

I, (Client/Legally Responsible Person), authorize Positive Growth Counseling Center to contact the individual and/or physician I have indicated below in the event I become incapacitated due to emergency illness or accident while in treatment. This emergency contact consent will be in lieu of any other authorizations, if any, I have granted, or not granted to the below individual.

I also will hold harmless Positive Growth Community Based Core Service Program against any liability caused by their taking of any emergency procedures and/or contacts. I agree to the Emergency Care Process as outlined above. I will assume the full responsibility of all incurred emergency treatment expenses.

I authorize Positive Growth, Inc. Counseling Center the holder of medical or other information about me to release any information necessary to process insurance claims, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to insurance assignment of benefits apply. I authorize Positive Growth, Inc. to provide, as necessary, to its contracted Qualified Service Organizations (e.g., laboratories, pharmacies, management information systems, billing and collection agencies) the following identifying information: my name, address, telephone number, date of birth, social security number, dates of service, and diagnostic code. This consent is valid until the above transactions related to my services are completed, not to exceed one year from the date below, unless and until I specifically revoke my consent to the release of any or all information at an earlier date.

I have read and understand the information regarding emergency contacts, emergency care and consent and the accounting of disclosure/release of information. All of the aforementioned forms have been explained to me.

I, (Client/Legally Responsible Person) have received a copy of the Clients' Bill of Rights and confidentiality handout and each has been explained to me.

Client/Legally Responsible Person

Date

Employee Signature

Date

CONSENTS FORM (optional)

CONSENTS FORM

AGREEMENT TO PAY:

AGREEMENT TO PAY: I agree to pay the established fee of $ per session or the pay plan each month. I understand that:

I may be denied an appointment and/or sent to Small Claims Court if I refuse to pay when I have the ability to pay.
It is my responsibility to inform the agency of any changes, which affect the billing or charges to my account.
I will be charged for a scheduled appointment if not canceled 24 hours in advance.
We will bill your Insurance Co., CMO or Third Party for services rendered. We ask that you pay your co-pay before each session.

ASSIGNMENT OF BENEFITS: (optional)

ASSIGNMENT OF BENEFITS: I authorize payment by my insurance company or Medicare/Medicaid to be paid directly to Positive growth, Inc. Community Based Services for services rendered. I understand that I am financially responsible to Positive growth, Inc. Community Based Services for charges applied to the insurance deductible and for all charges limited by the insurance carrier.

CLIENT:

RECORD NO:

CONSENT FOR SERVICES: (optional)

CONSENT FOR SERVICES: Positive Growth provides services to individuals who have emotional, developmental, and substance abuse problems. The staff members are trained to provide appropriate treatment as needed to help the individual. I present myself to receive services from Positive Growth, Inc. I understand that I have the right and responsibility to participate in all aspects of my plan for care. I can withdraw from services at any time. I consent to urine drug screens at any time during my treatment. If dissatisfied with decisions regarding my care, I can appeal those decisions or file a grievance. Information about me related to my services from Positive Growth, Inc. is confidential and may be privileged. This information is shared with staff involved in my care only on a need to know basis. It cannot be disclosed to a third party without my express consent except under special circumstances that include the following. Information about physical or sexual abuse, exploitation, neglect, or deprivation of a child or incapacitated adult will be reported as required by law. Positive Growth, Inc. will exercise its duty to warn other individuals if I threaten physical harm to them; if I threaten physical harm to myself, the Agency will exercise its duty to care and will take reasonable steps to protect me. In the event of a medical emergency jeopardizing my life or health, Positive Growth, Inc. will disclose to my medical emergency care provider the information necessary to permit accurate diagnosis and treatment. When a court of legal jurisdiction issues a proper subpoena or order, the information specified may be submitted to a court of law. Limited information may be provided to law enforcement serving an arrest warrant or investigating a crime. Auditors, reviewers, evaluators, and consultants who are both recognized as legitimate by Positive Growth, Inc.’s Executive Director and are bound to protect confidentiality may obtain information directly related to the execution of their official duties.

I agree to treatment as offered by Positive Growth for:

Myself

My Child

The person for whom I am legal guardian/custodian

Untitled

In the event I cannot bring my minor child or the person for whom I am legal guardian/custodian to the Program, then I give permission to bring the client to the Program and participate in treatment as needed.

CLIENT RIGHTS AND RESPONSIBILITIES: (optional)

CLIENT RIGHTS AND RESPONSIBILITIES: I have received the client rights handout and the relevant handouts outlining my responsibilities as a client of Positive Growth Community Based Core Services program. I understand that it is my right to ask questions if I need clarification or have concerns.

CONFIDENTIALITY: (optional)

CONFIDENTIALITY: In accordance with state and federal laws, information maintained about you at this agency will be protected from unauthorized disclosure. No information will be sent to your employer, family members, friends, or anyone else, unless it is discussed with you ahead of time and permission is obtained. Disclosure is permitted under state and federal laws for situations which may be applicable to you such as:

In the interest of public safety (life threatening situations)
In response to a court order Where state laws require that information be disclosed (e.g., suspected child or adult abuse, Communicable Disease)

Positive Growth Services requires reporting of non-identifying client information. This information is stored in a computerized record system for statistical, program planning, research, evaluation, and funding purposes.

Violation of the Federal and State laws and regulations by a program is a crime. Suspected violations may be reported to the U.S. Attorney in the district where the violation occurs.

The doctrine of informed consent has been explained to me and I understand the contents to be released, the need for information, and that there are statutes and regulations protecting the confidentiality of authorized information. I hereby acknowledge that this consent is truly voluntary. I further acknowledge that I may revoke, in writing, this consent at any time except to the extent that action based on this consent has been taken.

RELEASE OF INFORMATION FOR PAYMENT:

RELEASE OF INFORMATION FOR PAYMENT: I hereby authorize Positive Growth, Inc. Community Based Services to release the necessary information from my record as requested to . This data will include dates of service, types of services, diagnosis, name of person providing services, and the relevant charges. Other information requested may also include any alcohol/drug or HIV/AIDS related treatment. This information will be used to process claims only.

ACKNOWLEDGEMENT OF CHILD ABUSE/NEGLECT REPORTING REQUIREMENT: (optional)

ACKNOWLEDGEMENT OF CHILD ABUSE/NEGLECT REPORTING REQUIREMENT: All health and human service professionals are required by state law to report suspected abuse or neglect to the appropriate authorities. If you have any questions about this, please feel free to ask for a better understanding before you sign. Your signature below acknowledges receipt of this information.

PERMISSION FOR OFF-SITE ACTIVITIES: (optional)

PERMISSION FOR OFF-SITE ACTIVITIES: During the course of treatment, the client may on occasion, be off the premises attending therapeutic group outings. During these times, the client/parent/guardian agrees to release Positive growth, Inc. Counseling Center, Community Based Core Services Program from all liability and responsibility. Transportation will be provided by the program. This consent is valid until separation of client from the program or by written termination of permission by a parent/guardian/self.

Client/Legally Responsible Person

Date

Employee/Witness Signature

Date

ORIENTATION ACKNOWLEDGMENT

ORIENTATION ACKNOWLEDGMENT

Untitled

I have been furnished a copy of the POSITIVE GROWTH, INC. Orientation Packet which explains the mission of POSITIVE GROWTH, INC. and the services it offers.

I have been furnished a copy of POSITIVE GROWTH, INC. ethical standards and understand that all reported violations of the ethical standards will be investigated.

I have been furnished a Notice of Privacy Practices.

I understand that, with special exceptions, information regarding my treatment is confidential and will be released to other parties only with my written consent. I have been furnished a summary of the rules and procedures Involving confidentiality.

I understand that I, and in some cases my family, will play an active role in setting my goals and planning my services. I understand that a person will be assigned to be responsible for the overall coordination of my services. I will be given the name of this person at the conclusion of the intake process. This person is referred to in the Orientation Packet as my "Service Coordinator".

I understand that I have specific rights as an Individual and that a procedure exists to process any complaints I may have. I have been furnished a list of my rights and the name of the persons I should contact if I have a complaint. I understand that, when necessary, behavior management procedures may be used to prevent injury to myself or others or the destruction of property. I understand I can review these procedures with the person responsible for the overall coordination of my services.

Any fees that I will incur from receiving services at Positive Growth, Inc. and the payment expectations for these fees have been explained to me.

I understand that while I am receiving services, periodic confidential surveys may be conducted by mail, face-to-face, and/or by phone, inquiring as to my satisfaction with services. Also, I understand that after completing services, confidential follow-up may be conducted by mail and/or by phone. I understand that my records may be reviewed by representatives from licensing and accreditation agencies and organizations.

My signature below indicates I understand all of the points listed above and have been furnished a copy of all of the documents referenced.

Individual Signature:

Date:

Parent/Guardian Signature:

Date:

Witness’s Signature:

Date:

Individual Rights

Individual Rights

Untitled (optional)

The right to agree to and approve of your treatment.
The right to be involved in planning your treatment.
The right to a written Individualized Service Plan (ISP) and be promptly and fully informed of any changes in the plan.
The right to have services provided in a way that fits your individual characteristics, needs, and abilities.
The right to review and obtain copies of your service record unless the physician or other determines it authorized staff not to be in your best interest.
The right to understand how to give permission to release or obtain information about your treatment, as well as how to revoke the permission.
The right to be free of physical abuse, sexual abuse, harassment or physical punishment.
The right to be treated with respect, dignity and kindness, free of mental abuse, such as humiliation, being threatened or taken advantage of.
The right to know funds are used for providing treatment instead of financial gain.
The rights to be informed of how to get other help you may need through referral to: a) guardians or conservators, b) self-help groups, c) advocacy services, and d) legal services.
The right to be provided with information to help you make the best decisions.
The right to express who you want for a case manager, therapist, or other service provider.
The right to know how to use services when you are in a crisis.
The right to be free of any physical restraint or time-out procedure except for the purpose of providing effective treatment and protecting your safety and other persons.
The right to have and retain personal property, which does not jeopardize your safety or the safety of other Individuals and have such property treated with respect.
The rights to written information that explains when the use of treatment interventions and restriction of rights would occur.
The right to know the limitations of confidentiality.
The right to privacy with respect to your past, present, and future mental health and medical information.
The right to receive treatment in the least restrictive environment available.
The right to refuse service, unless it is determined by a physician, licensed clinician or licensed psychologist that you are unable to care for self, is dangerous to yourself or others or is mandated by a court.
The right to receive clinically appropriate treatment even if it is determined you are unable to pay.
The right to be fully informed of the charges for treatment.
The right to obtain a copy of the program’s most recently completed report of licensing inspections forms.
The right to request clarification if you have any questions regarding these rights.
The right of referral to legal entities for appropriate representation, and to self-help and advocacy support services.
The right to exercise all civil, political, personal, privacy and property rights to which you are entitled to as a citizen.
The right to remain free of psychological abuse, including humiliating, threatening, and exploiting actions.
The right to file a complaint if you think any of these rights have been restricted or denied. Information on how to file a complaint or contact your Individual's Rights Representatives is presented on a poster near the reception desk at every service site.

Call or Write to: 404-657-5557. Office of Regulatory Services, ORS, Complaint Intake Unit, 2 Peachtree Street, Atlanta, GA 30303, 404-657-7857. Division of MHDDAD, 2 Peachtree Street, Atlanta, GA 30303

I have reviewed these rights. I have received a copy of these rights and understand that a copy will be placed in my medical record.

Individual Signature:

Date:

Parent/Guardian Signature:

Date:

Individual Name (printed)

Insurance:

Client Information and Office Policy Statement (optional)

Client Information and Office Policy Statement

Untitled (optional)

Welcome!

Thank you for participating in services provided by Positive Growth, Inc. Counseling Center. This is an opportunity to acquaint you with information relevant to treatment, privacy practices and office policies. The PGCC staff will answer any questions you have regarding any of these policies. Your case will be assigned to a counselor, clinician and/or community support individual as soon as possible. The first step for our agency is to complete an Intake, Orientation and Diagnostic Assessment. The purpose of this process is to orientate the Individual and family to our program, gather necessary information and presenting problems, discuss your rights, grievances process, and your input with the quality of care you can expect to receive. Towards the conclusion of this initial appointment you will have provided the assessment team with background information, strengths, needs and preferences of the Individual, input in treatment planning, as well as, a clear understanding of the transition/discharged plan. The counselor, clinician and/or community support individual assigned to the case will both participate in this process. This initial appointment will be scheduled during regular office hours to facilitate a timely case opening.

After the initial diagnostic assessment is complete, the designated staff person will schedule regular weekly or bi monthly appointments. Services can begin immediately if you (your client) have the flexibility to be seen during the mornings or early afternoons. If they need a later time for ongoing services, they can then schedule for later in the day as an evening slot becomes available. If this is not possible, ongoing services will commence as soon as an evening appointment is open on a regular basis. It is essential that you communicate this to your client family.

It is our responsibility to contact the client. Our staff will make several attempts to set up an appointment within the week of case assignment. If we do not get confirmation or response, we will notify you and the case will be placed on hold until further discussion with you, regarding the client's readiness for services. This same procedure will be followed for a pattern of missed appointments.

If you or the client family contacts PGCC requesting another attempt to engage in services, the referral may be assigned to the next available therapist or counselor, depending on the length of time that may have elapsed.

Our office is located at 945 North Indian Creek Drive, Clarkston, GA 30021; we are open Monday through Friday from 9 a.m. to 8 p.m. and Saturday 9 a.m. to 12 p.m. Since we are a community-based program, our staff maintains flexible hours during days, evenings, and weekends by appointment. Please be aware that our services are available to you 24/7 for emergency purposes.

Please feel free to call us with your concerns or comments, we encourage your feedback.

Sincerely,

Joseph T. Arnold, LPC, NCC, GCADC III

Director

1. The Goal of Services: (optional)

The major goal is to help you and/or your family identify and cope more effectively with problems in daily living and to deal with issues which may disrupt your ability to enjoy personal and family health and happiness. General goals of service delivery:

To increase personal awareness and understanding of family dynamics, relationships, issues, problems and strengths.

To identify personal treatment goals.
To increase personal responsibility and to make changes necessary to attain your goals.
To promote wholeness and well being through emotional, cognitive and behavioral health treatments, and psychiatric treatment when necessary.
You are responsible for providing necessary information to facilitate effective treatment. You are expected to play an active role in your treatment, including working with your PGCC professional to outline your treatment goals and assess your progress. You have the right to refuse treatment. There may also be negative consequences if you do not follow through with recommended treatment(s).

You may be asked to complete questionnaires or to do homework assignments. Your progress in therapy often depends much more on what you do between sessions than on what happens in the session.

2. Appointments: (optional)

Appointments vary in length of time. When scheduled, you will be advised of the anticipated length of your scheduled session. PGCC's hours are available for day and evenings appointments. Clients are generally seen weekly or more/less frequently as needed and you and your PGCC professional arrange. You may discontinue treatment at any time, but please discuss any decisions with the PGCC staff. In the event of an emergency, call local emergency resources such as the Police Department or contact afterhours County Department of Family and Children Services on call.

3. Confidentiality: (optional)

Issues discussed in sessions are important and are generally legally protected as both confidential and "privileged." However, there are limits to the privilege of confidentiality. As Mandated Reporters, we are obligated to report: 1.) Suspected abuse or neglect of a child, elderly person or a disabled person, 2.) Other examples when the PGCC staff believes you are in danger of harming yourself or another person or you are unable to care for yourself, 3.) If you report that you intend to physically injure someone, the law requires the PGCC staff inform that person as well as the legal authorities/other situations may arise where information may be shared, 4.) If PGCC staff is ordered by a court to release information as part of a legal involvement in company litigation, etc., 5.) When your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc., 6.) In natural disasters whereby protected records may become exposed or 7.) When otherwise required by law. You may be asked to sign a Release of Information so that the staff may speak with other mental health professionals or to family members that you have in the past or currently are involved with you and/or your family.

4. Record Keeping: (optional)

A clinical chart is maintained describing your treatment and progress in treatment, dates of service delivery and notes describing each session. Your records will not be released without your written consent, unless in those situations as outlined in the Confidentiality section above. Only designated staff have access to your file for office procedure purposes.

5. Fees and Payments: (optional)

There are fees for services and we will provide services according to the rules surrounding the benefit set of your insurance, Medical Assistance, or County Purchase of Service contract. Services will be provided in the authorized service timeframe and agreed upon frequency. Please note that we need you to sign for authorization of payment if you have insurance. Fees vary according to the service being provided. You may have information about the specific fee for the service at your request. You may call 404-298-9005 for information. Generally, services are provided in increments of 15 minutes with a typical session being 45-50 minutes in length. Some specialized services that we provide may involve longer sessions given the nature of the service and funding.

It is important that you communicate any changes in your insurance or Medical Assistance that may affect your coverage for services. Change of benefit coverage may result in your responsibility to pay for services rendered.

Persons who have co-pay responsibilities are expected to provide full co-pay payment at the point of service delivery. We do not accept: credit cards, promises to pay, partial payment; and respectfully request you bring the exact payment as we have limited cash on hand to make change.

Persons who wish to self-pay may contact PGCC's Clinical Director to discuss fees and details surrounding payment by calling 404-298-9005.

6. Cancellations and Missed Appointments: (optional)

It is important that you keep your scheduled appointments. If you are unable to keep the appointment, it is expected you cancel 24 hours prior to the appointment. This allows the service professional to schedule other appointments in the time period. The service professional will attempt to be flexible in scheduling appointments with you. You may be billed ($25.00) for missed appointments. If you decide to discontinue participation in services, the courtesy of your advising us of that would be greatly appreciated.

7. Complaints: (optional)

We strive to have your experience be satisfactory but should you have a concern, complaint or suggestion, please communicate that to the professional who has been working with you or contact the Clinical Director or UM/Quality Assurance Manager and discuss the situation. If you do not feel the complaint has been resolved, you may also inform your insurance carrier and file a complaint if you so choose. OR YOU MAY WRITE OR CALL: Office of Regulatory Services, ORS, Complaint Intake Unit 2 Peachtree Street Atlanta, GA 30303 Telephone (404) 657-5726.

8. Signature Requested: (optional)

You will be provided a form to sign concerning Positive Growth, Inc’s Privacy Practices, your consent to treatment and authorization for payment.

9. Mandated Reporting: (optional)

The mandated reporting laws are designed to protect children and vulnerable adults, unborn children and the public generally. Professionals at PGCC who work with you are mandated reporters and are required by law to report any child abuse and neglect concerns.

10. Duty to Warn: (optional)

Under certain circumstances, the PGCC professional is required/permitted to warn others of the potential violent or dangerous behavior of the client. These warnings may be given without the client's consent.

11. Consent for Release of information: (optional)

To better provide services to you, it is at times necessary to consult with other professionals that have knowledge of you. Specific information to be released/ obtained may include: psychological and psychiatric evaluation or testing; family and social history, medical records; chemical dependency evaluation; school records; financial and health insurance data, consultations/termination summary from previous service providers and other data as specified. Your information can only be disclosed or released with your valid, informed consent. The consent includes: 1) To whom your records may be released. 2) The purpose for the release. 3) Expiration date for the authorized released.

12. Request for Copies of Client File: (optional)

If you should desire a copy of materials from your file; please send a written request to Positive Growth Counseling Center requesting specific materials. Please note there is a standard file handling charge of $25.00 plus copy cost for reproduction expense. Payment in advance is needed in order to process your request.

13. Our Commitment to Safety in Service Delivery for You and for Staff: (optional)

We provide an array of services to children, teens, individual adults, couples and families. We provide those services utilizing an: Community Family Based Services model where we meet with folks in their homes, community, schools, jobs, etc.; site-based model where services are provided at the PGCC offices. We also provide comprehensive programming to youth who reside in out-of-home placements: foster care and/or group home. We are very committed to providing a pleasant and safe environment for people when they came to our offices for services and we expect that everyone will respect the property and the privacy of any other clients you may happen to meet while you are here. Also please note that your supervision of your children is expected and will be appreciated.

14. PGCC IS A SMOKE FREE CAMPUS. (optional)

Please refrain from smoking in our building and on

grounds. Thank you for your anticipated cooperation. PGCC also bans guns on its premises.

15. (optional)

15. For families who are being seen in their home; please note that it is important that you plan to

greet your PGCC professional at the door when they arrive. Arrange for adequate light in the

doorway and yard so that they may approach your home safely. If you have pet dogs, birds,

snakes, etcetera; we kindly request you contain them so that they do not frighten or pose

threat to staff. Please refrain from smoking and chemical use during the sessions.

16. Feedback: (optional)

We welcome your feedback on how we have done in being helpful to you. Please offer critical comments as well as positive comments regarding your experience at PGCC. We hope to be helpful and appreciate your support of our efforts to be a resource for you. May you thrive in your health and happiness.

Notice of Privacy Policy (optional)

Notice of Privacy Policy

THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY

Our Commitment to Protect Your Mental Health and Medical Information (optional)

You have a right to privacy with respect to your past, present, and future mental health and medical information. Positive Growth, Inc. is required by law to protect your information and to provide you with this Notice of our legal duties and privacy practices with respect to your protected health information. You have the right to receive a paper copy of this Notice. An electronic copy of this

We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. In the event this Notice is revised, you may request a paper copy of the revised notice or view the revised notice at the above web address.

How We May Use and Disclose Your Protected Health Information (optional)

We use and disclose protected health information for a variety of reasons. In general, our use and disclosures fall within the following three categories: treatment, payment, and health care operations.

Treatment – We will use your protected health information and disclose it to others as necessary to provide treatment to you. For example, members of our clinical staff may access your record in the course of your care, or share information in the process of coordinating your care. Such staff members include physicians, psychologists, nurses, and other mental health professionals. Additionally, disclosure to another facility, community health center, or private practitioner may become necessary for your continued treatment.

Payment – We will use or disclose your protected health information as necessary to arrange for payment of services provided to you. For example, information about your diagnosis and the services we provide to you may be included in a bill that we send to a third-party payer.

Health Care Operations – We will use or disclose your protected health information in the course of operating Positive Growth, Inc. Centers or for the health care operations of another organization that has a relationship with you. For example, our quality assurance staff reviews records to ensure that our high standards of treatment delivery are reached consistently. In addition, Positive Growth, Inc. may contract with outside companies, or “business associates”, such as consultants, accountants, lawyers, and medical transcriptions, to provide services that may involve the use of your protected health information.

Unless you instruct us otherwise, we may also send appointment reminders, information about treatment options and other health-related benefits that may be of interest, and other similar materials to you.

Uses and Disclosures Requiring Your Authorization (optional)

We are generally prohibited from using or disclosing your protected health information for purposes other than treatment, payment, and health care operations without your written authorization, unless the use or disclosure is within one of the categories described below. In addition, we generally may not use or disclose psychotherapy notes written by your mental health provider without your written authorization, even for treatment, payment and health care operations. You have the right to revoke your authorization in writing at any time, except to the extent that we have already undertaken an action in reliance upon your authorization.

Uses and Disclosures Not Requiring an Authorization (optional)

By law, we may use or disclose certain of your protected health information without an authorization in the following circumstances:

When required by law – We may disclose protected health information when a law requires that we report information about suspected abuse, neglect, or domestic violence, or relating to certain criminal activity, or in response to a court order. We must also disclose protected health information to authorities that monitor our compliance with these privacy requirements.

For public health activities – We may disclose certain protected health information to public health agencies as permitted or required by law.

For health oversight activities – We may disclose certain protected health information to certain government agencies for oversight activities authorized by law.

Judicial and Administrative Proceedings – We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information in certain cases in response to a subpoena, discovery request, or other lawful process, subject to your notice and opportunity to object.

Relating to deceased individuals – We may disclose certain protected health information related to death to pursuant to a valid subpoena of a coroner or medical examiner.

To avert a serious threat to health or safety – We may disclose protected health information, in order to avoid a serious threat to your health or safety and the health and safety of the public or another person.

For specific government functions – We may disclose protected health information as required by military authorities, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment, and for national security and intelligence reasons, such as protection of the President.

Uses and Disclosures of Alcohol/Drug Treatment Records (optional)

At Positive Growth, Inc., personally identifying information related to the treatment of substance abuse has special legal privacy protections. We will not disclose any information identifying you as an Individual of our services or provide any mental health or medical information relating to substance abuse treatment except in certain circumstances, including but not limited to: (1) you consent in writing; (2) a court orders disclosure of the information after a show cause hearing as required under Georgia Law; (3) medical personnel need the information to meet a medical emergency; (4) qualifying personnel use the information for the purpose of conducting research, management audits, or program evaluation; or (5) it is necessary to report a crime or threat to commit a crime or to report child abuse or neglect as required by law. As applicable, you will be provided an additional notice regarding the confidentiality of substance abuse information.

Uses and Disclosures to Which You May Object (optional)

In the following situations, we may disclose a limited amount of your protected health information if we inform you in advance and you do not object, as long as law does not otherwise prohibit the disclosure:

To families, friends, or others involved in your care – We may share with these people certain information directly related to their involvement in your care, or payment for your care. We may share certain protected health information with these people to notify them about your location, general condition, or death.

Patient directories – Your name, location, and general condition may be put into a facility patient directory for disclosure to callers or visitors who ask for you by name. Additionally, your religious affiliation may be shared with clergy.

Your Rights Regarding Your Protected Health Information

You have the following rights with respect to your protected health information:

To obtain access to your protected health information – You generally have the right to see and obtain copies of your protected health information upon written request. We may deny you access to review or copy your protected health information. If your request is denied, we must provide you with a reason for the denial and explain any right to have the denial reviewed. If we grant your written request for copies of your protected health information, we will advise you in advance of any fees we may impose for the costs of copying and mailing.

To request restrictions on uses and disclosures – You have the right to ask that we limit how we use or disclose your protected health information. We will consider your request, but are not legally bound to agree to the restriction. If we do agree to any restriction, we will put the agreement in writing and abide by it except in the case of emergency situations. We cannot agree to limit uses and disclosures that are required by law.

To receive confidential communications – You have the right to request that we communicate with you by using an alternative address or by alternative means. We must agree to your request as long as it is reasonable for us to comply.

To an accounting of disclosures – You have the right to receive upon written request an accounting of when; to whom, for what purpose, and what content of your protected health information has been released for the past six years. This list will not include the following instances for disclosure: for treatment, payment, and health care operations; to you, to your family, or for a facility directory; or pursuant to your written authorization. The list of disclosures will not include any certain other disclosures, such as those made to law enforcement officials or correctional facilities, for national security purposes, or disclosures made before January 1, 2007. There will be no charge for the first accounting you request within a 12-month period. For additional lists within the same period, we will advise you in advance of any fees we may impose.

To request an amendment – If you believe that your protected health information is incorrect or incomplete, you have the right to request in writing that we amend the information. Your request must include the reason you are seeking a change. We may deny your request if (1) we did not create the information, or the information is not part of our records; (2) the information is not permitted to be disclosed; or (3) the information is correct and complete. Any denial must be in writing and must state the reasons for the denial and explain your right to submit a statement of disagreement and to have your statement (and any rebuttal), along with your request and the denial, appended to your record.

Notice of Privacy Policy

TELEMENTAL HEALTH ACKNOWLEDGMENT

Consent for Telemental Health Services: I, , understand that Positive Growth, Inc. Community Based Services also provides telemental health as an additional format for services to include mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communication. “Telemental health means the mode of delivering services via technology-assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, pc desktop system or other electronic means using appropriate encryption technology for electronic health information. Telemental health facilitates client self-management and support for clients and includes synchronous interaction and asynchronous store and forward transfers.” (Georgia Code 135-11-01). This format is used in lieu of face-to-face sessions when necessary (ie., physical incapacities, in times of natural disasters, global pandemics).

Client Information and Office Policy Statement (optional)

ACKNOWLEDGEMENT OF RECEIPT

By signing this Acknowledgement of Receipt, you acknowledge that you have received a copy of the Telemental Health Acknowledgement and Notice of Privacy Practices of Positive Growth, Inc. Our Notice of Privacy Practices describes and contains information about our legal duties and privacy practices and about your legal rights with respect to your protected health information. We encourage you to read our Notice of Privacy Practices in full.

I acknowledge receipt of the Notice of Privacy Practices of Positive Growth, Inc.

Individual Name (Printed):

Individual Signature:

Date:

Parent/Guardian Signature:

Date:

PGCC Representative Signature:

Date:

Treatment Agreement Signature Page (optional)

Treatment Agreement Signature Page

Individual’s Name:

Date:

Therapist:

PP/CSI/CM: (optional)

Insurance: (optional)

Treatment Plan Start/End Date: (optional)

Was the treatment plan reviewed with Individual and Guardian? (optional)

Yes

Therapist: What goals and objectives should be the primary focus of the work? (optional)

PP/CSI/CM: What goals and objectives should be the primary focus of the work? (optional)

I am allowing Positive Growth Inc. to authorize more units for services. (optional)

I am allowing Positive Growth Inc. to authorize more units for services.

Individual Signature

Date

Parent Signature

Date

Therapist/Assessor Signature

Date

PP/CSI/CM Signature

Date

Lic. Supervisor Signature (required for PP/CSI/CM and ST):

CRISIS MANAGEMENT AND SAFETY PLAN (optional)

CRISIS MANAGEMENT AND SAFETY PLAN

I, the undersigned, agree that I will not do anything that would cause harm to myself or anyone

else. I realize that I am responsible for my own actions, and that if I feel my life is becoming too

difficult, by initialing below, I agree to do one or more of the following safety actions so there is no harm to myself or others.

Untitled

I will contact Positive Growth Inc. at 404-298-9005 or call the after-hours line at 404-287-6647

I will contact my assigned Therapist or CSI worker.

I will contact the Georgia Crisis & Access Line (GCAL) at: 1-800-715-4225

I will contact the National Suicide Prevention Lifeline at: 1-800-273-8255

Untitled (optional)

I understand that Positive Growth Inc. and all of my treatment team are concerned with my safety and the safety of others. It is their duty to protect and warn of such dangers.

I understand there will be a crisis management and safety plan created and implemented for me which identifies any possible triggers/emotional and behavioral management needs.

I understand prevention strategies, responsible parties and management intervention/steps will be listed to help resolve any safety issues which may arise.

Individual’s Signature

Date

Employee/Witness Signature

Date