1 Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Intensive Outpatient Program Participant Handbook
2 Table Of Contents: Welcome..... Page 1 Introduction. Page 1 Staff Page 1 Informed consent... Page 1 What to expect.. Page 2 Appointments.... Page 2 Fees and Payment... Page 2 Confidentiality... Page 2 Consultation and supervision. Page 3 Treatment records. Page 3 Emergency Services.. Page 3 Signed Consent for treatment Page 3 Notice of Privacy Practices.. Page 5 What is this notice...page 5 Some useful definitions...page 5 How do we use and disclose... Page 5/6 Other ways health information can be disclosed. Page 6 Privacy rights. Page 6/7 Our duties to you.... Page 7 Questions or complaints Page 8 Group information. Page 10 Group rule.... Page 10 Schedule Page 10 Phase Transitions & Graduation. Page 10 Transportation. Page 10 Drug Testing.. Page 11 Calling out Page 11 Emergency Procedures. Page 11
3 Welcome to the Family Willows Participants of the Family Willows Intensive Outpatient Program will work with their treatment team to create an individualized treatment plan that will depend on their unique needs. Treatment includes individual therapy, case management, trauma and addiction psycho-education, and group therapy. Introduction The Family Willows is committed to individualized treatment, discharge and aftercare to meet the complex needs. Our IOP program can last up to 16 weeks, participants will be individually assessed for readiness for discharge or for adjustments in treatment plans. The Family Willows staff with work with you to reduce substance use and harmful behaviors in your life by building skills that will allow you to be more independent and self-sufficient. You will have many opportunities to learn and discuss these principles during the course of treatment. Please ask your treatment team to explain anything you do not understand or answer any questions you may have. Family Willows Staff Meghan Shea, MSW, LICSW, MLADC, Program Manager Emily MacDonald, BA, Intake Coordinator Katie Gordon, BSW, LADC, Treatment Coordinator Michelle Lattime,MS, Treatment Coordinator Ashley Kitchell, Recovery support worker Informed Consent for the Family Willows Intensive Outpatient Program (IOP) Your Rights: As a client of Families in Transition, you have several rights. You have the right to: Decide not to enter intensive outpatient services, decide not participate in specific types of services, and to decide to terminate services at any time. A safe environment, free from emotional, physical, and sexual abuse. Be treated with respect by self, staff, and other clients. Be free from discrimination from self, staff, and other clients, including but not limited to racial, sexual, religious, age, gender, or economic discrimination. Complete and accurate information about your treatment including goals, methods, potential risks and benefits, and progress. Information about the professional capabilities and limitations of any professional involved in your treatment. Receive treatment from trained and qualified professionals. Written information about fees, payment methods, and lengths and duration of sessions and treatment. Be informed about the limits of confidentiality, the situations in which your counselor and/or the agency is legally bound to disclose information to outside persons or agencies, and the types of information that will be disclosed. Know if your counselor will discuss your case with supervisors or peers. Request a summary of your treatment. Request the release of your clinical information to any agency or person that you choose.
4 Be referred to appropriate community services, based on individual needs, as we are able to identify them. If you are asked to leave the program, to know why you are being asked to leave and what conditions you must meet in order to return to Families in Transition. File a grievance with Families in Transition if you feel that any of your rights have been violated. 1 What to expect from the Family Willows IOP: Counseling is a process in which you work with a counselor in order to resolve problems and meet agreed upon goals. Counseling is not like a visit to a medical doctor. Rather, it calls for a very active effort on your part. In order for counseling to be most successful, you will have to work on things that are discussed both during sessions and at home. Counseling can have risks and benefits. Counseling often involves discussing unpleasant aspects of your life and you may experience uncomfortable feelings as a result. However, counseling has also been shown to help individuals resolve specific problems and reduce feelings of distress. Appointments: Sessions are normally 50 minutes and are scheduled based upon your needs. We ask that you be on time for appointments. If you need to cancel or reschedule an appointment, please contact your counselor as soon as possible. If you do not show up for two (2) sessions in a row, your counselor may terminate services. We will bill you for missed appointments that have not been canceled or rescheduled at least 24 hours in advance at your normal session rate. Fees and Payment: We provide services based on a sliding fee scale ranging from no fee to $70 per session. Although we will not refuse services to any eligible person because of an inability to pay, we ask that you attempt to contribute something to the cost of your counseling. Families in Transition does not have agreements with any insurance providers for reimbursement and, as such, you are responsible for the cost of all services provided to you. Payment of fees for services is expected on the day that services are delivered and any balance must be paid in full prior to receiving additional services unless special arrangements are agreed upon with your counselor. Confidentiality: The confidentiality of client records maintained by Families in Transition is protected by federal law and regulations. Generally, we may not say to a person outside of this agency that a client receives services here, or disclose any information identifying a client as an alcohol or other drug abuser. The exceptions to this include (a) with written consent from you, (b) if the disclosure is permitted by court order, (c) the disclosure is made to medical personnel in a medical emergency, or (d) to report suspected child abuse and neglect or suspected elder or incapacitated adult abuse, neglect, or exploitation. In addition, the New Hampshire Department of Health and Human Services Bureau of Community Health Services is authorized to review our records to ensure that we are providing quality services. Violation of the federal law and regulations by this agency is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal guidelines. Federal law and regulations do not protect any information about a crime committed by a client either on Families in Transition property, against any person who works for Families in Transition, or any threat to commit such a crime. (See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for federal laws and 42 CFR part 2 for federal regulations)
5 2 Consultation and Supervision: Each counselor at Families in Transition participates in regular clinical supervision and peer case consultation with clinicians who are bound by the same standards of confidentiality. The goal of this supervision and consultation is to provide the most effective and helpful services to our clients and to continually improve our skills as clinicians. As part of this supervision and consultation, your counselor may request your permission to audio- or videotape sessions with you. We assure you that these tapes will be used only for quality assurance and supervisory purposes. Tapes will be erased after being reviewed. If you do not want your sessions to be taped (in whole or part), you are under no obligation to consent to this request and your eligibility for services will not be affected. Treatment Records: The laws and standards of professional counseling mandate that we keep records of your treatment. You have the right to receive a copy of your record, or we can prepare a summary of your treatment for you instead. Due to the professional nature of these records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend that you arrange to do so in the presence of your primary counselor so that the contents can be discussed. We reserve the right to withhold the release of your records to outside agencies if you have an outstanding balance. Emergency Services: In the event of an emergency when your counselor is not available, please contact the Families in Transition Hotline at (603) or This source of support is available to you 24 hours a day, 7 days a week. Signed Consent for Treatment: Please read the following statement and indicate your agreement by signing below. My counselor and I have agreed that my fee for services will be $ week. If at any time my fee becomes a problem, I will discuss it with my counselor during our session. I have read and/or had explained all of the preceding statements and understand my rights and responsibilities for the services rendered by Families in Transition. I agree to these conditions of my counseling as provided in this agreement. Client Signature Date Counselor Signature Date
6 3 Signed Consent for Treatment: Please read the following statement and indicate your agreement by signing below. My counselor and I have agreed that my fee for services will be $ per week. If at any time my fee becomes a problem, I will discuss it with my counselor during our session. I have read and/or had explained all of the preceding statements and understand my rights and responsibilities for the services rendered by Families in Transition. I agree to these conditions of my counseling as provided in this agreement. Client Signature Date Counselor Signature Date Consent to Record Counseling Sessions: I hereby give consent (initial)/do not give consent (initial) to my counselor at the Families in Transition, Inc. to: videotape (initial if Yes) audiotape (initial if Yes) our counseling sessions. These recordings will be used to aid the counseling process and to gain further understanding of important aspects of the treatment. I have discussed this procedure with my counselor. I understand that refusal to consent to taping will not affect my eligibility for receiving services at this agency. Client Signature Date Counselor Signature Date
7 4 Notice of Privacy Practices What is this notice? This notice was prepared to provide you with an understandable explanation about how we may "use" and "disclose" your "protected health information." Health information is an indispensable part of healthcare treatment, payment and operations; without access to health information, the healthcare system cannot function. A Federal Law called the Health Insurance Portability and Accountability Act (HIPAA), or the Privacy Rule, was created to support your privacy and rights surrounding your health information. We understand that health information about you is very personal. Families in Transition is committed to insuring the privacy and confidentiality of your personally identifiable health information. All employees and volunteers must sign a confidentiality agreement when hired. An informed client is an important ally for us in meeting these goals. We hope you will take the time to read our notice and to call us if you have any questions. Some useful definitions: Protected Health Information ("PHI") - Any information, created by us in any form that identifies and is related to the past, present, or future: 1) Physical or mental health of the individual; 2) Provision of health care to the individual; or 3) Payment for health care provided to the individual. If all personal identifiers have been removed from the information, it is considered "de-identified health information" and may be used more freely than protected health information. "Uses" and "Disclosures" - We use these terms as they are defined in the Privacy Rule. We "use" your protected health information when we examine, review, analyze, or share it within Families in Transition, Inc. We "disclose" your protected health information when we release, transfer, provide access to, or share it in any other way with any other organization or individual, for example to a state agency or to a referring provider. How do we use and disclose your protected health information? The Privacy Rule permits us to use and disclose your "protected health information" (PHI) for treatment, payment, and healthcare operations. Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, require that we ask for your written consent to disclose your protected health information. The following describes in general how we may use or disclose your health information for treatment, payment, and health care operations: Treatment: We may use or disclose your health information to provide and coordinate your treatment. Families in Transition may use or disclose your health information among members of your treatment team or other personnel within Families in Transition. If healthcare providers outside of Families in Transition request your health information, we will ask you for your written consent before sharing the information.
8 Payment: We may use and disclose health information about you so that the services you received from us may be billed for and payment collected. Health Care Operations: We may use and disclose health information about you within Families in Transition to make sure that you receive quality care. For example, we may use health information to review our services, to evaluate the performance of our staff, or to review your records if you file a complaint. 5 What other ways may we use and disclose your health information? Public Health Information (these are required by law): We may use or disclose your health information when necessary to prevent a serious threat to your health or safety or to the health or safety of others. For example, health information may be used or disclosed for an Involuntary Emergency Admission or to report abuse or neglect of minors, elders, or dependent adults. Health Oversight Activities: We may disclose health information to a health oversight agency for them to make sure we are following the law. (Audits, inspections, investigations, or licensure) Emergency Situations: If an emergency happens to you, we may need to release your health information, without your consent, to medical personnel so they can treat you. As Required by Law: We may disclose health information about you in situations not already mentioned when required to do so by federal, state, or local law. Research: We may disclose your health information to researchers when you have agreed to participate in a study. Law Enforcement Activities: We may disclose health information to a law enforcement official for law enforcement purposes when the information is needed to identify or locate a suspect, fugitive, material witness, or missing person; to report a death that may be the result of criminal conduct; to report criminal conduct occurring on our premises; if we receive a court order or subpoena to produce your health information; if a medical examiner requests your health information; or to the State or District Attorney s Office if you are the victim of a crime. Such releases of information will only be made after reasonable efforts to contact you for your authorization. If we cannot contact you, we will obtain legal advice, but we may be required to release your records. What are your privacy rights? The Federal Privacy Rule gives you several new rights with respect to your protected health information (in addition to those rights you already have under state law). Beginning April 14, 2003, you have the following rights to your health information: Right to a Paper Copy of this Notice: You have the right to receive written notice of our privacy practices (That's this document.) If you have received this notice electronically, you have the right to a paper copy if you want it. Right to Request Restrictions: You have the right to ask for further restrictions on the ways in which we use and disclose your protected health information. We are not required to agree to a requested restriction. We will not agree to any request unless we feel that we can fully meet our commitment. Right to Request Confidential Communications: You have the right to ask that we communicate with you in a certain manner or at a certain location. We will make efforts to accommodate reasonable requests. You must make this request in writing.
9 6 Right to Inspect and to Copy: You have the right to see and get a copy of your treatment record or any other protected health information that we keep in a regular paper or electronic file. We may charge you a reasonable fee for copies, consistent with state law. You must make this request in writing. We may ask for a verification of identity as you make these requests. (Note: There are a few situations specified in the Privacy Rule where this right does not apply.) Right to Request an Amendment: You have the right to ask for an amendment of your protected health information. Entries are not deleted from medical records because of legal requirements but may be corrected or amended by the author of the entry. You may request an amendment of your treatment record or other protected health information that we keep in a regular file. You must make this request in writing. If the information is accurate and complete as determined by the author of the entry, we will decline the request for amendment but will include your request and statement of disagreement in your file. Right to Request a List of How We Shared Your Health Information: You have the right to receive a written accounting of the disclosures we have made of your protected health information. This accounting does not include disclosures for treatment, payment or healthcare operations, disclosures authorized by you, and certain other exceptions. You must make this request in writing. Right to Designate a Personal Representative: You have the right to designate a "Personal Representative" to help you exercise your rights concerning your protected health information. This personal representative must be designated in writing, and must show this designation any time he or she wishes to exercise the rights attached to it. New Hampshire State laws apply to the rights and responsibilities of personal representatives. Our duties to you: We are required by law to maintain the privacy of your personal health information, and to give you notice of our legal duties and privacy practices with respect to your protected health information. We are required to abide by the terms of our Privacy Notice currently in effect. We reserve the right to change our privacy practices (that is, to change the ways in which we use or share your protected health information as described in the Notice), so long as the new practices are permitted by the Federal Privacy Rule or other applicable law, and are described in a revised Notice of our privacy practices. We further reserve the right to make any such revised Notice provisions effective for all protected health information we maintain, including information created or received before the effective date of the revised Notice. Revised Notices will be posted in service locations, and will be available on request from Families in Transition.
10 7 Questions or Complaints? If you have a question or believe your privacy rights have been violated, you may request clarification or file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. Families in Transition s Privacy Officer will assist you with your complaint, if you request such assistance. Privacy Officer Secretary, Dept. Of HHS Families in Transition U.S. Department of Health and Human Services 122 Market Street Office of Civil Rights Manchester, NH Independence Avenue, S.W. Phone: (603) RM 515 F HHH Bldg. Washington, D.C Phone: (202) Toll-Free All complains must be submitted in writing. We will respond to all properly filed complaints. You will not be adversely affected or discriminated against in any way for filing any such complaint.
12 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I have received a copy of the Families in Transition Notice of Privacy Practices. I understand that Families in Transition has the right to change its Notice of Privacy Practices from time to time and that I may contact Families in Transition at any time to obtain a current copy of the Notice of Privacy Practices. Client Name (Print) Signature of Client/Legal Representative Relationship to Client Date FOR OFFICE USE ONLY PRINT PLEASE I have attempted to obtain the patient s signature on this form, but was not able to for the following reason: Please document the reasons you were unable to obtain the signature. Date: Initials:
13 Group information Family Willows IOP Group Rules: Confidentiality - What is said in group stays in group. Non-judgment - Use I statements. Respect Treat others as you wish to be treated. Participate Actively participate in group. No Cell Phones - Cell phones must be turned off and placed on the table in front of you. You may only have your phone on with the permission of the group for anticipated critical calls. Food Healthy snacks may be brought into group. Junk food and fast food will not be allowed. No alcohol or drugs on FIT property If you are required to take medications during IOP hours, you must provide a doctor s note. Staff request that mothers limit disruption to child care room by not visiting during breaks Schedule: Phase 1 Mondays, Wednesdays, and Fridays 9am 12pm Phase 2 Tuesdays & Thursdays 9am 12pm Childcare will open for drop-off at 8:30am. Please have your child dropped off prior to 9am so that you may join group on time. Phase Transitions & Graduation: Movement from Phase 1 to Phase 2 will be decided based on completion of program goals and your personal goals. When you believe you have completed both the goals of the Phase and your goals for that Phase, you will be asked to submit a request to transition, which you will present to the group for discussion and feedback. Upon the group s and IOP Team s approval, you will be graduated to Phase 2. Graduation from the program as a whole will be determined by accomplishment of program goals and your personal goals. You will submit a request to the group describing your completion of goals and your recovery/aftercare plan. Upon the group s and IOP Team s approval, you will graduate. Transportation: Transportation is an exceptionally limited resource! Thus, we must maintain several strict rules. o Drivers will only wait 3 minutes for you. If you are not out waiting for us or do not come out quickly, we will leave and it will count as a no show for transportation. o You must cancel transportation by 9pm the previous evening. If you do not and do not show, it will count as a no show for transportation. o If you do not show for transportation twice, you will lose transportation services. 10
14 Drug Testing: Drug test results will be discussed at the time of the drug test. It is important to do this so that this tool is focused on supporting your treatment and recovery journey, versus punishment. Drug tests will include urine screens as well as a breathalyzer Thus, drug testing will be conducted during individual counseling and case management sessions. However, if you miss your individual appointments for the week, a drug test will be conducted during group and your results will be discussed in group. Staff my conduct random screens during group. If you are unable/unwilling to provide a urine sample your records will reflect a positive test as a result. Calling Out: Please call extension 1707 to call out: FIT Transportation: call by 9pm the day prior Child Care Services: call by 7:30am the day of IOP programming: call by 7:30am the day of *You must call out prior to the times indicated above or it will be considered a NO SHOW *If you no show child care or transportation a warning letter will be send sent. One more no show of child care or transportation after a warning letter has been received will lead to termination of either of these services. * Weather cancellations: Family willows closes according to Manchester School District snow emergencies. If Manchester schools are cancelled or delayed due to a weather emergency, IOP will also be closed Emergency Procedures: It is extremely important to reach out for help in an emergency! What is an Emergency?: At any time you feel that you are experiencing symptoms of your trauma or addiction such as severe anxiety or depression, you feel you may hurt yourself or someone else, you feel you may use substances. 1. Contact your IOP primary therapist and treatment coordinator if it is during programming hours. 2. If not during program hours, call Families in Transition s Hotline number: Clinical Emergency Phone: *Manchester Emergency Shelter will be screening the initial call. Clinical staff will call you back in a timely fashion 3. If you cannot reach anyone, go to your nearest hospital emergency room, or call
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Jennifer L. Trotter, Ph.D. Telephone: 248-880-4966 - Email: JenniferLTrotter@gmail.com Licensed Clinical Psychologist Address: 25882 Orchard Lake Road - Suite L-4 - Farmington Hills, MI 48336 OUTPATIENT
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LiveWell Group 7781 Cooper Road 2 nd floor Suite 5 Cincinnati OH, 45242 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
Anna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030 PSYCHOLOGIST - PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about
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Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. About this notice
JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT This document contains important information about my professional and business policies. It also
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Important Notice
NOTICE OF PRIVACY PRACTICES THIS NOTICE OF PRIVACY PRACTICES ( NOTICE ) DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.
9129 Monroe Rd. Suite 100, Charlotte, NC 28270 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax email@example.com www.jgarydolinskyphd.com Psychologist-Patient
TRAINING MANUAL HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 HIPAA Table of Contents INTRODUCTION 3 What is HIPAA? Privacy Security Transactions and Code Sets What is covered ADMINISTRATIVE
James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc. 89 Moraga Way, Suite B Tel: 925-285-2429 Orinda, CA 94563 Fax: 925-429-9259 Name
SCA INTAKE DOCUMENTS Thank you for your interest in Southwest Counseling Associates. This package contains all the documents you would typically receive when you arrive for your first session with an SCA
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Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 CONSENT FOR EVALUATION AND TREATMENT Welcome to my practice. This document