Individual Intake Forms

Transcription

1 PFEIFER & ASSOCIATES Individual Intake Forms Alcohol Services & Supports Program Before services can be rendered at Pfeifer & Associates, new Individuals must complete the following intake forms. Upon completion you will receive an Individual Handbook and be assigned a counselor.

2 VERIFIABLE URINALYSIS ANALYSIS In order to satisfy Oregon s mandate to monitor the sobriety of our Individuals, we need accurate and verifiable urinary analysis (UA s) A diluted UA cannot be verified as negative and can lengthen your Services & Supports unnecessarily. Individuals are responsible for the cost of additional UA s. We may also find it necessary to refer you to a doctor for examination for various physical ailments. IE: diabetes or kidney problems. We have consulted our UA lab and they suggest that the Individual drink no more than 8oz. of water in the four hours prior to attending groups. Due to the fact that we are contracted by the State of Oregon to monitor sobriety, a second diluted UA will be considered positive for substances and the Individual will need to start Services & Supports again. Individual signature: Print name: Staff signature: Date:

3 PAYMENT INFORMATION Select form of payment. This will give us an idea of possible payment options. INSURANCE COMPANY NAME: BILLING ADDRESS: PHONE: POLICY NUMBER: SELF-PAY NAME TO BE BILLED: Phone: Address: City: State: SLIDING FEE APPLICATION To qualify for sliding fee scale you must first be eligible for food stamps. Please ask for the application to see if you qualify. By signing this form you are granting consent to use and disclose your protected health information for the purpose of Services & Supports, payment and health care operations. Individual signature: Print name: Date:

4 FEE SCHEDULE PLEASE LEAVE BLANK UNTIL ASSESSMENT Group $40 Individual $35 Family $66 Assessment $50 Urinalysis Testing $25/$60 (dependent on test) Level One Assessment & UA, 3 Individual sessions, 12 Groups, & 2 UA s. Level One - Intervention Assessment & UA, 3 Individual sessions, 24 Groups, & 2 UA s. Level One Assessment & UA, 3 Individual sessions, 36 Groups, & 2 UA s. Approximate Cost $ Interactive Journaling Packet additional $10 Approximate Cost $ Approximate Cost $ Fees are estimates based upon minimum Services & Supports requirements. Fees will be higher if your individual Services & Supports needs indicate further care. I, agree to pay the cost of my Services & Supports. Estimated cost of Services & Supports is $. I understand that payment is due at the time of service and I will be charged $25 for any returned checks. Individual signature: Print name:

5 RELEASE FOR SERVICES & SUPPORTS Date: Supplying the SSN is voluntary & in general the refusal to supply the SSN cannot be used to deny services. The SSN is necessary for identifying records for employment & vocational rehabilitation information. In either case, if supplied, the SSN may be used to enforced agency regulations. Date of Birth Social Security Number: I authorize PFEIFER & ASSOCIATES to release information to: Referring Agent: Phone: Fax: I authorize the : to release information to Pfeifer & Associates. I consent to the exchange of the following information, including: (please initial each line) Records of family history. Alcohol/Drug Services & Supports. Mental Health services. Medical/Psychiatric Services & Supports. Educational reports. I agree that the agencies & individuals listed above may share and exchange information. Yes No Individual signature: Purpose: The information received will be used to evaluate your situation, to plan for & coordinate services for you & your family. For purposes not specified above: This permission is good for one year or until REVOKED IN WRITING. I can cancel this at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that the information about my case is confidential and protected by State and Federal law. I approve the release of this information. I understand what this agreement means. I am signing on my own and not been pressured to do so. Individual Guardian Parent Legal Custodian SIGNATURE DATE: STAFF SIGNATURE DATE:

6 RELEASE FOR SERVICES & SUPPORTS FOR PERSONS WHO CANNOT WRITE My Mark: Date: Business #1 Business #2 Address: Address: RELEASE FOR SERVICES & SUPPORTS FOR PERSONS WHO CANNOT READ I have read the form to the Individual. He/She understands it & signed it voluntarily. Staff Name: Individuals Name: INSTRUCTION 1. The worker should fill out this form for the Individual. Be sure the Individual understands it before signing. Encourage the Individual to question the form & what it allows. 2. Mail requests: If this form is being used to request information by mail, be specific about what you need. If you have a series questions, use a cover letter. The clearer you are in your requests, the more likely you are to receive a prompt and accurate response. Do not ask for information you do not need. 3. Family records: This release covers information about the person signing the form, minor children and information about the family he/she supplied for the record. It would not cover information supplied by other adult family members unless they also sign a release. 4. Children: Minors can consent to medical Services & Supports at age 15, mental, emotional or chemical at age 14. They may sign their own permission for release of information forms needed for such Services & Supports. 5. Photocopying: Keep the original in the file and send copies to other agencies. The person making the photocopies should sign the copy, at the bottom of the page, to certify it is a true copy. 6. Re-Disclosure: Information received under this authorization should not be re-disclosed without specific written consent. Criminal penalties may apply to illegal disclosure. Federal regulation (42CFR Part 2) prohibits you from making any further disclosures of alcohol and drug information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. 7. Revocation: If the person later cancels this authorization write, REVOKED, the method by which authorization was cancelled and the date boldly across the form. Date and initial the page, store it in the file. Federal regulations do not allow us to require that that revocation be in writing. 8. Duration: The authorization is valid for one year or as otherwise specified. Check to be sure that the release you are using is still current. 9. HIV: this form should not be used to request information about HIV testing. Use the form developed by the Oregon Health Division. 10. Guardianship/ Custody: If the signer is a guardian, a copy of the guardianship paper must be attached when the request is sent. Similarly, if an agency has custody, and their representative signs the custody order should be included. 11. Refusal of consent: This is a voluntary form. Individuals should be given accurate information on how the refusal to allow the release or misinformation will adversely affect eligibility determination or coordination of services. If the Individual decides not to sign, attain to refer the family to a single service, which may be able to help them without exchange of information.

7 EMERGENCY CONTACT Supplying the SSN is voluntary & in general the refusal to supply the SSN cannot be used to deny services. The SSN is necessary for identifying records for employment & vocational rehabilitation information. In either case, if supplied, the SSN may be used to enforced agency regulations. Date of Birth Social Security Number: I authorize PFEIFER & ASSOCIATES to release information to: EMERGENCY CONTACT NAME: Phone: This permission is good for one year or until REVOKED IN WRITING. I can cancel this at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that the information about my case is confidential and protected by State and Federal law. I approve the release of this information. I understand what this agreement means. I am signing on my own and not been pressured to do so. Individual Guardian Parent Legal Custodian SIGNATURE DATE: STAFF SIGNATURE DATE:

8 MEDTOX RELEASE Supplying the SSN is voluntary & in general the refusal to supply the SSN cannot be used to deny services. The SSN is necessary for identifying records for employment & vocational rehabilitation information. In either case, if supplied, the SSN may be used to enforced agency regulations. Date of Birth Social Security Number: I authorize PFEIFER & ASSOCIATES to release information to MEDTOX: Phone: Fax: I authorize MEDTOX to release information to Pfeifer & Associates: Services & Supports (INITIAL) Alcohol/Drug Alcohol/Drug, Mental Health and medical records include all aspects of diagnosis, Services & Supports and prognosis. Educational records include both behavioral and progress reports. I agree that the agencies and individuals listed above my share and exchange information. Yes No Purpose: The information received will be used to evaluate your situation, to plan for & coordinate services for you & your family. For purposes not specified above: This permission is good for one year or until REVOKED IN WRITING. I can cancel this at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that the information about my case is confidential and protected by State and Federal law. I approve the release of this information. I understand what this agreement means. I am signing on my own and not been pressured to do so. Individual Guardian Parent Legal Custodian SIGNATURE DATE: STAFF SIGNATURE DATE:

9 MEDTOX RELEASE FOR PERSONS WHO CANNOT WRITE My Mark: Date: Business #1 Business #2 Address: Address: MEDTOX RELEASE FOR PERSONS WHO CANNOT READ I have read the form to the Individual. He/She understands it & signed it voluntarily. Staff Name: Individuals Name: INSTRUCTION 1. The worker should fill out this form for the Individual. Be sure the Individual understands it before signing. Encourage the Individual to question the form & what it allows. 2. Mail requests: If this form is being used to request information by mail, be specific about what you need. If you have a series questions, use a cover letter. The clearer you are in your requests, the more likely you are to receive a prompt and accurate response. Do not ask for information you do not need. 3. Family records: This release covers information about the person signing the form, minor children and information about the family he/she supplied for the record. It would not cover information supplied by other adult family members unless they also sign a release. 4. Children: Minors can consent to medical Services & Supports at age 15, mental, emotional or chemical at age 14. They may sign their own permission for release of information forms needed for such Services & Supports. 5. Photocopying: Keep the original in the file and send copies to other agencies. The person making the photocopies should sign the copy, at the bottom of the page, to certify it is a true copy. 6. Re-Disclosure: Information received under this authorization should not be re-disclosed without specific written consent. Criminal penalties may apply to illegal disclosure. Federal regulation (42CFR Part 2) prohibits you from making any further disclosures of alcohol and drug information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. 7. Revocation: If the person later cancels this authorization write, REVOKED, the method by which authorization was cancelled and the date boldly across the form. Date and initial the page, store it in the file. Federal regulations do not allow us to require that that revocation be in writing. 8. Duration: The authorization is valid for one year or as otherwise specified. Check to be sure that the release you are using is still current. 9. HIV: this form should not be used to request information about HIV testing. Use the form developed by the Oregon Health Division. 10. Guardianship/ Custody: If the signer is a guardian, a copy of the guardianship paper must be attached when the request is sent. Similarly, if an agency has custody, and their representative signs the custody order should be included. 11. Refusal of consent: This is a voluntary form. Individuals should be given accurate information on how the refusal to allow the release or misinformation will adversely affect eligibility determination or coordination of services. If the Individual decides not to sign, attain to refer the family to a single service, which may be able to help them without exchange of information.

10 DMV RELEASE Supplying the SSN is voluntary & in general the refusal to supply the SSN cannot be used to deny services. The SSN is necessary for identifying records for employment & vocational rehabilitation information. In either case, if supplied, the SSN may be used to enforced agency regulations. Date of Birth Social Security Number: I authorize PFEIFER & ASSOCIATES to release information to DMV: Phone: Fax: I authorize DMV to release information to Pfeifer & Associates: Supports Alcohol/Drug Services & Alcohol/Drug, Mental Health and medical records include all aspects of diagnosis, Services & Supports and prognosis. Educational records include both behavioral and progress reports. I agree that the agencies and individuals listed above my share and exchange information. Yes No Purpose: The information received will be used to evaluate your situation, to plan for & coordinate services for you & your family. For purposes not specified above: This permission is good for one year or until REVOKED IN WRITING. I can cancel this at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that the information about my case is confidential and protected by State and Federal law. I approve the release of this information. I understand what this agreement means. I am signing on my own and not been pressured to do so. Individual Guardian Parent Legal Custodian SIGNATURE DATE: STAFF SIGNATURE DATE:

11 DMV RELEASE FOR PERSONS WHO CANNOT WRITE My Mark: Date: Business #1 Business #2 Address: Address: DMV RELEASE FOR PERSONS WHO CANNOT READ I have read the form to the Individual. He/She understands it & signed it voluntarily. Staff Name: Individuals Name: INSTRUCTION 1. The worker should fill out this form for the Individual. Be sure the Individual understands it before signing. Encourage the Individual to question the form & what it allows. 2. Mail requests: If this form is being used to request information by mail, be specific about what you need. If you have a series questions, use a cover letter. The clearer you are in your requests, the more likely you are to receive a prompt and accurate response. Do not ask for information you do not need. 3. Family records: This release covers information about the person signing the form, minor children and information about the family he/she supplied for the record. It would not cover information supplied by other adult family members unless they also sign a release. 4. Children: Minors can consent to medical Services & Supports at age 15, mental, emotional or chemical at age 14. They may sign their own permission for release of information forms needed for such Services & Supports. 5. Photocopying: Keep the original in the file and send copies to other agencies. The person making the photocopies should sign the copy, at the bottom of the page, to certify it is a true copy. 6. Re-Disclosure: Information received under this authorization should not be re-disclosed without specific written consent. Criminal penalties may apply to illegal disclosure. Federal regulation (42CFR Part 2) prohibits you from making any further disclosures of alcohol and drug information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. 7. Revocation: If the person later cancels this authorization write, REVOKED, the method by which authorization was cancelled and the date boldly across the form. Date and initial the page, store it in the file. Federal regulations do not allow us to require that that revocation be in writing. 8. Duration: The authorization is valid for one year or as otherwise specified. Check to be sure that the release you are using is still current. 9. HIV: this form should not be used to request information about HIV testing. Use the form developed by the Oregon Health Division. 10. Guardianship/ Custody: If the signer is a guardian, a copy of the guardianship paper must be attached when the request is sent. Similarly, if an agency has custody, and their representative signs the custody order should be included. 11. Refusal of consent: This is a voluntary form. Individuals should be given accurate information on how the refusal to allow the release or misinformation will adversely affect eligibility determination or coordination of services. If the Individual decides not to sign, attain to refer the family to a single service, which may be able to help them without exchange of information.

12 PATIENT/FINANCIAL SPONSOR INFORMATION FORM ASSIGNMENT OF BENEFITS Patient/Financial Sponsor (P/FS) hereby assigns to Pfeifer & Associates any group or personal hospital benefits or any other insurance benefits otherwise payable directly to patient/sponsor on account of the Services & Supports care provided to patient. Patient/Financial sponsor understands he/she is solely responsible for the cost of Services & Supports regardless of any potential insurance coverage. Patient/Financial sponsor agrees that a photocopy of this assignment is as effective as the original. FEES AND LOSSES In the event that any unpaid account balance is referred to a collection agency or attorney for collection, patient/sponsor agrees whether or not suit is commenced to pay all costs and expenses incurred in the collection process including but not limited to collection agency fees. WAIVER OF CONFIDENTIALITY Patient/Financial sponsor realizes records may contain information relating to alcoholism, drug addiction, HIV/AIDS status as well as mental health or other specially protected information. Patient/sponsor specifically authorizes the release of this information. Patient/Financial sponsor understands that in the event of a financial delinquency owed to this facility, a signature on this form constitutes a waiver of any right or privilege of confidentiality that patient/financial sponsor may have under Federal law. Patient/Financial sponsor understands that he/she may revoke this consent at any time but that no revocation will be effective for the collection of obligations incurred before the revocation. Patient/Financial sponsor understands the above information as well as a detailed billing summary and any other information or documents pertinent to successful collection of debt incurred with this institution may by furnished to any credit service collection agency or attorney appointed by institution and/or be introduced into evidence in the event a lawsuit is filed for collection of obligation. Patient/Financial Sponsor Print Name: Witness Print Name:

13 DESCHUTES COUNTY 2011 VICTIM S IMPACT PANEL SCHEDULE REQUIRED FOR DUII INDIVIDUALS ONLY This program includes testimonials from victims of DUII crashes telling how impaired drivers have adversely affected their lives and may include graphic images. Cost is $25.00 (Cash or Money Order only) Registration & payment to the Deschutes county District Attorney s Office located at: 1164 NW Bond Street, Bend Or Must register and pay during District Attorney s office hours Payment will not be accepted at the time of the class Program is from 6-8pm on the last Wednesday of every month Doors lock at 6pm, late entry not allowed Guest may attend, at no charge, as long as there is available seating No attendees under 12 years of age, due to graphic material Proof of attendance is provided at the end of the program. The attendee is responsible for providing that proof to the court or Services & Supports provider. You only need to attend once during treatment Classes are held at the Deschutes County Services Building 1300 NW Wall Street (Intersection of Lafayette Ave. & Hill St.) Bend Oregon, January 26, 2011 July 27, 2011 February 23, 2011 August 31, 2011 March 30, 2011 September 28, 2011 April 27, 2011 October 26, 2011 May 25, 2011 November 30, 2011 June 29, 2011 December 28, 2011 Questions? Call Victims Assistance at

14 NICOTINE QUESTIONNAIRE FOR PFEIFER & ASSOCIATES Name: Date: 1. Have you ever used nicotine in any form? Yes No 2. Do you currently use nicotine? Yes No 3. If so, how old were you when you first used nicotine? 4. How much do you presently use? 5. Do you wish to quit using? Yes No 6. Would you like help quitting? Yes No

15 A Partial Listing of Medications DANGEROUS to People Recovering from Chemical Dependency. All medications that are mood altering- EVEN THOSE PRESCRIBED- should be taken with extreme caution. Over The Counter Medications (O.T.C s) Cough Medicine: Vicks44, Nyquil, Romilar, Robitussin, Terpin Hydrate Elixir, Pertussis Plus Mouth Washes: Listerine, Scope, Colgate (Most cough meds & Mouth washes contain alcohol- check with your pharmacist.), Antihistamines: Coricidin, Contact, Dristan, Benadryl, Chlor-Trimeton, Polaramine, etc. Sleep Preparations: Sleep-Eze, Compoz, Mr. Sleep, Sominex, Sure Sleep, Quiet World, Nytol, Alva Tranquil Miscellaneous: Gevrabon, Brondecon liquid, Geritol liquid, nervine, Parepectiolin, Paregoric, Kao-Pectin, Anbesol Other Prescription Medications, O.T.C s & Street Drugs Stimulants: Cocaine, Benzedrine, Dexedrine, Methamphetamine, Desoxyn, Diet Pills, Pep pills, etc. Barbiturates: Nembutal, Sodium Amytal, Seconal, Phenobarital, Tuinal, etc. Sedatives: Placidyl, Noludar, Doriden, Methaqualone, Quallude, Valmid, etc. Anagesics: Darvon, Darvecel, Phenaphen, etc. Antidepressants: Parnale, Tofranil, Elavil, Triavil, etc. Muscle Relaxant: Robaxin, Robaxisal, Soma Compound Norgesic, Paraton Forte, Norlex, etc. Tranquilizers: Valium, Librium, Tranxene, Meprobamates, Equanil, Miltown,Serax, Vistaril, etc. Major Tranquilizers: Thorazine, Compazine, Slelazine, Sparine, etc. Narcotic Analgesics: Talwin, Codeine, Methadone, Perdoan, Dilaudid, Heroin, Hycodan, Demerol, Morphine, etc. AntiSpasmodic: Tincture of Belladone, Belladone, Bentyl with Phenobarb, Bentyl, ProBanthine, Donnatal all forms, Kolantyl Wafers, Livrax, Roninul w/phenobarb, Pathilon, Pathibamale Tablet, etc. Anti-Asthmatic: Medihalerall compounds & drugs, Amesec, Alupent, Isuprel, Bronkometer, Bronkosol, Primatene, Asthmametric liquid, Elixophylin Elixer, etc.