STOPPING DRINKING WITHOUT MEDICATION. Client Registration & Information Pack

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1 STOPPING DRINKING WITHOUT MEDICATION Client Registration & Information Pack CONSENT CONTRACT FEEDBACK COMPLAINTS INSTRUCTIONS PLEASE EITHER: Complete and save and to me printing your name where it asks for a signature OR Print and complete and send to me in the post: Hr Doomsford, Burrington, Umberleigh, Devon EX37 9NE

2 ABOUT THIS TREATMENT PROGRAMME It's important to note that this is a low intensity programme to help people with their alcohol consumption, who are otherwise stable and well. It is not suitable for people who: Routinely need to drink to relieve withdrawal symptoms like sweating and shaking Have a history of suicide attempts, deliberate self harm or overdosing, or who have suffered significant mental health problems or psychological trauma Have ever had a fit or seizure for any reason Have compulsions to drink that are so overwhelming that they put themselves or others at risk This kind of programme is unlikely to work if you have repeatedly sought professional help with your drinking in the past with no sustained success. The programme is for three months, and usually consists of: (i) An Assessment & Planning appointment, when we will discuss options and then come up with a plan that suits you (ii) Structured Support Structured support is via telephone or Skype. Followed by an agreed combination of: This consists of 8 sessions by appointment, with the following suggested structure: Twice a week in the first week Weekly for 2 weeks Fortnightly thereafter. (however these may be moved around to suit you) These may be face-to-face, or 'at distance' i.e. by telephone or Skype. This is an opportunity for us to have a general catch-up, to look at any problems you're having or that you anticipate, and to check that your plans seem comprehensive and appropriate. These sessions can be any length up to an hour. (iii) Ad Hoc contact Informal, ad hoc contact throughout the programme by telephone or text as and when you need it: this is not by appointment, and I will reply as necessary and subject to my availability. (iv) A written treatment manual With comprehensive advice and instructions

3 Details of Agreed Treatment Plan Assessment & Planning Appointment ) Ad Hoc contact ) as defined on previous page Written treatment manual ) Total number of structured appointments: Of these: Face-to-face at your home Face-to-face in Exeter Clinic By telephone or Skype Over the duration of months When we book a time to talk by telephone or Skype, please treat these as you would any other appointment: be prompt, and give me as much notice as possible if you want to rearrange Any other details: Total Cost: Terms This cost is applicable only if paid in full in advance or at the time of our first appointment. Otherwise treatment must be paid for on a session-by-session basis (ask for details or see website) but a the fee quoted above is substantially discounted. Payment is by cheque, BACS transfer or PayPal. I am unable to take card payments. My decision to treat naturally depends on full disclosure from you of any physical or mental health diagnosis or symptoms, either currently or in the past, and of any previous help you have sought for any physical, psychological/psychiatric or addiction problem. If you fail to disclose information as asked that affects my ability to treat you safely and effectively, then I reserve the right not to treat you, and to charge for any expenses accrued. Refunds: refunds are not made if you choose not to use services paid for in advance, unless in exceptional extenuating circumstances. Should I, due to unforeseen exceptional circumstances, be unable to provide you with the services outlined above then you will be offered a proportionate refund.

4 Consent to Treatment Treatment Choices I have had the different choices about my treatment outlined to me. I have read the page of this document called ABOUT THIS TREATMENT PROGRAMME and confirm that I am not physically dependent on alcohol, and that I have no mental or physical health problems outlined therein that would make this programme unsuitable. I have disclosed full details of my physical and mental health in the past as well as the present, including details of all previous treatments received. Consent to Share Information I agree that information about my treatment may be shared with the following nominated people (eg supportive partner, friend or family member. You need not nominate anyone if you do not wish to do so): I understand that the Care Quality Commission, who govern and monitor this healthcare provider under statute, may examine my clinical record, and contact me about my treatment, to monitor the quality of treatment delivered. I understand that this service employs an external assessor to help monitor the quality of service provided, who will be a qualified health or social care professional bound by professional confidentiality. This assessor has controlled access to my clinical record for the purposes of quality assurance. I understand that my information may be shared on a need to know basis with any appropriate agency under statute or common law if Mark Jay believes that I or members of the public are at risk if he fails to act. I understand that I may withdraw my consent to share information at any time and this may result in a reduction of services being available. I understand that I have the right to restrict what information may be shared and with whom, but this may affect the provision of care to me. I understand that my information will be held securely on paper and on secure computer drives in accordance with the Data Protection Act SIGNED NAME DATE

5 Name Date of Birth or Age Address & Postcode Your Information Telephone Numbers GP (for exceptional emergency use only) Next of Kin Name Relationship Address Telephone (for exceptional emergency use only)

6 Statutory Equality and Diversity Monitoring Ethnicity How would you describe yourself? Choose ONE section White British English Irish Scottish Welsh Any other White background, please write: B Mixed Heritage White and Black Caribbean White and Black African White and Asian Any other Mixed background, please write: C Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background, please write: D Black or Black British Caribbean African Any other Black background, please write: D Black or Black British Caribbean African Any other Black background, please write: E Chinese or other ethnic group Chinese Any other, please write: E Prefer not to say Equality and diversity monitoring Disability Do you consider yourself to have a disability or a long-term health condition? Yes No Prefer not to say If Yes, what is the effect or impact of your disability or health condition? Gender Would you describe yourself as: Male Female Other (eg TG) Please write: Prefer not to say

7 How to make a complaint I always try to learn from what clients tell me about the treatment they ve received whether it is good or bad. Feedback helps me to make improvements to services. Making a complaint Anyone who is affected or likely to be affected by the actions or decisions of my service can make a complaint. If you cannot do this yourself then someone else, usually a carer, relative or close friend can do it for you, but only with your agreement. Please say if you are complaining on behalf of someone else as I will need to obtain written consent before I can share personal information with you. Stage 1 Problems and concerns can often be dealt with most easily by speaking to me. So if you can, let me know about any problem. The sooner I know, the sooner I can try to help. Stage 2 If you want to make your complaint formal, please write to: Mark Jay, Higher Doomsford, Burrington, Umberleigh, Devon, EX37 9NE; or by to (note that s are not a secure way of communicating sensitive personal information) What happens next? I will respond to you within two working days of your complaint being received. I will respond to your complaint within 20 working days. This response will include a clear rationale for the findings, which if appropriate will refer to agreed clinical guidelines or professional standards. Stage 3 If after this stage you remain dissatisfied, I will bring in a third party to investigate and try to resolve the matter. Nursing and Midwifery Council (NMC) The NMC will investigate any complaint from a member of the public who feel that the actions of a nurse or midwife may be putting the safety of patients or the public at risk. They can be contacted on or Care Quality Commission (CQC) The CQC monitors and regulates this healthcare provider. Please note, however, that they do not investigate individual complaints. You can contact them with any concerns over the service you have received on , cqc.org.uk or th_care_or_social_care_service_july_2013.pdf Mark Jay BSc (Hons) RMN

8 Client Feedback Your feedback on the treatment you have received is important and helpful, and it is hugely appreciated if you can take the time to complete an online form here: You can also write at any time to comment on the service you have received. All feedback is documented and acted upon, and is available to the Care Quality Commission as part of their monitoring, unless you do not consent to this.

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