Brantford Native Housing Residential Support/ Addiction Treatment Program

Size: px
Start display at page:

Download "Brantford Native Housing Residential Support/ Addiction Treatment Program"

Transcription

1 Brantford Native Housing Residential Support/ Addiction Treatment Program Application Package Ojistoh House or Karahkwa House 318 Colborne Street East Brantford, ON N3S 3M9 (519) x 235 T (519) F

2 Brantford Native Housing Addiction Residential Support Program Application Process Background The Residential Support Addiction Treatment Program is offered through Brantford Native Housing. This program is offered to Aboriginal men (Karahkwa House) and women (Ojistoh House) (18 +) who are in recovery from drug and/or alcohol use. Residents can stay in the Residential Support Addiction Treatment Program for up to one (1) year and receive up to two (2) years of supports while residing in the community. Residents must have four months of abstinence from all alcohol and illicit drugs and have abstinence as your goal to qualify for the program. Brantford Native Housing provides addiction programming that incorporates both Aboriginal specific health and healing programming as well as cognitive behavioural and biopsychosocial addiction treatment models. Residents will be expected to maintain abstinence from all alcohol and recreational (mood altering) drugs while residing in the Residential Support Addiction Treatment Program and participate in programming. Application Process Brantford Native Housing Residential Support Addiction Treatment Program is transitional housing. It is expected that Applicants have attended an in-patient residential treatment program or received extensive outpatient treatment support. We require all incoming applications to be completed by a community service agency/addiction treatment program. Self referrals also accepted if references (agencies you are/have worked with) provided. Completed applications can be faxed to: Transitional Support Worker Once we receive the completed application forms, a Brantford Native Housing staff person will contact the Applicant within one (1) week to schedule an intake interview to assist in determining eligibility and obtain any additional necessary information for review of the application. Eligibility Criteria 1. At least 50% of the family (female Applicants bringing children) must be of Aboriginal ancestry. Male Applicants must be of Aboriginal ancestry; 2. Applicant must be in need of housing due to homelessness or at-risk of homelessness (i.e., living in a shelter, temporarily staying with family or friends, etc.); Brantford Native Housing Residential Support Addiction Program Application Page 2 of 13

3 3. The Applicant must be 18 years of age or older; 4. The Applicant must be eligible for Ontario Works, ODSP or other income programs, if not working or attending school or a training course; 5. Committed to paying service fees; 6. Committed to the aftercare program (if coming from a treatment program) and/or full abstinence from drugs/alcohol and participate in our treatment programming, which includes individual counselling, group counselling and attendance in a peer support group; 7. Committed to connecting with community resources and moving toward an independent and healthy lifestyle; and 8. Applicants must agree to sign our Consent to Obtain Information form with the referring community service agency and other service providers the Applicant is working with. Brantford Native Housing Residential Support Addiction Program Application Page 3 of 13

4 Residential Support / Addiction Program Application Form Ojistoh House (Female) Karahkwa House (Male) APPLICANT NAME: Date of Birth: Aboriginal Ancestry: First Nations Status Métis First Nations Non-status Inuit Applicant Band and Number: Applicant Address: Telephone/Fax: APPLICANT DEPENDENTS: 1. Name: DOB: Age: Aboriginal Ancestry: Gender: 2. Name: DOB: Age: Aboriginal Ancestry: Gender: 3. Name: DOB: Age: Aboriginal Ancestry: Gender: 4. Name: DOB: Age: Aboriginal Ancestry: Gender: 5. Name: DOB: Age: Aboriginal Ancestry: Gender: Brantford Native Housing Residential Support Addiction Program Application Page 4 of 13

5 APPLICANT INCOME: 1. What is the Applicant s last source of income? 2. Does the Applicant receive child support payments? 3. Does the Applicant understand that she/he is required to pay service fees to stay in the Addiction Residential Support Program? Yes No REFERRING AGENCY INFORMATION: Name of Agency: Name/Position: Address: Telephone/Fax/ 1. Is the Applicant able to complete daily living chores? 2. Does the Applicant have any disabilities? APPLICANT INFORMATION: 1. Does the Applicant have any children that are not in their care and will not be staying with the Applicant? Yes No 2. Where is the Applicant presently living? Shelter Family/friends Hotel/Motel Other How long? 3. Are there any safety issues/concerns regarding current or past intimate relationships? Yes No Restraining order Peace bonds Custody orders CAS conditions Other If yes, please explain: Brantford Native Housing Residential Support Addiction Program Application Page 5 of 13

6 4. Is the Applicant on Probation or Parole? Yes No If yes, who is the Probation/Parole Officer? Contact info: 5. What other agencies/service providers is the Applicant currently working with? Ontario Works C.A.S Probation & Parole Mental Health Supports Counselling Legal Services Public Health Services Training Program Employment Services Other, please explain 6. History of Drug/Alcohol Use: Drug/Alcohol used Age when 1 st used Age when last used 7. History of Drug/Alcohol Treatment: Has the Applicant been to Detox? No Yes - Date Has the Applicant recently attended an Addiction Treatment Program? No Yes, where and when? Does the Applicant have an Aftercare Plan? No Yes (attach copy) Does the Applicant have a Sponsor? No Yes Brantford Native Housing Residential Support Addiction Program Application Page 6 of 13

7 8. What wellness steps has the Applicant taken? Support System Therapy/Counselling AA NA Anger Management Group Therapy Cultural Activities Other 9. Is the Applicant on the Methadone program? Yes No If yes, where does the Applicant access the meds and who manages their participation? Current Dose: Length of time in Methadone Program and history of dose: 10. What other goals will the Applicant be working on not related to substance use? 11. Who does the Applicant include as support during crisis? Name: Relationship Contact Information: Brantford Native Housing Residential Support Addiction Program Application Page 7 of 13

8 12. Emergency Contact Persons: Name: Relationship: Contact Information: APPLICANT EDUCATION: Some High School High School Grad GED Some College College Grad Some University University Grad Technical/trade certified Training APPLICANT WORK HISTORY: Is the Applicant currently employed? Yes No Employer: Address: Telephone/Fax: Position: Work hours: Salary/Wage per hour Does the Applicant have an up-to-date resume? Yes No Does the Applicant want to work? Yes No HEALTH INFORMATION: 1. Are there acute medical complications that may require referrals to emergency or hospital for immediate medical assessment? Yes No Brantford Native Housing Residential Support Addiction Program Application Page 8 of 13

9 2. When did the Applicant last see a physician? Doctor: Phone #: Address: 3. Does the Applicant have any life threatening allergies? Food Environment Medicine If yes, please explain: 4. Does the Applicant carry an Epipen for allergies? Yes No 5. Is the Applicant currently in any type of treatment or counselling for emotional or mental health problems? Yes, where? No 6. Was the Applicant hospitalized in the last year? If yes, for what reason. Yes No 7. List all current medications, dose and the reason for taking it. Medication Dose Reason for Taking 8. Health Screening: Check all that apply. Diabetes Epilepsy or seizures Cancer Eating disorders Heart disease High/Low Blood pressure Liver disease Kidney disease Asthma Menstrual/menopausal difficulties Brantford Native Housing Residential Support Addiction Program Application Page 9 of 13

10 Pregnancy Pancreatitis Physical or sexual abuse Emotional/verbal abuse Recent untreated injury Tuberculosis ~ TB Sexually transmitted disease Lice/scabies Stomach problems Tuberculosis Head injury Hepatitis A B or C Please add any additional information that will assist our understanding of the Applicant s needs. Brantford Native Housing Residential Support Addiction Program Application Page 10 of 13

11 Brantford Native Housing Addiction Treatment Program Brantford Native Housing provides a supportive residential addiction treatment program and an outpatient structured relapse prevention group and limited short-term individual counselling for individuals concerned about alcohol and drugs. This program is designed to help individuals review their lifestyle, identify changes they would like to make, and help them develop the necessary skills to make those changes. Referrals to residential treatment programs or community programs are provided. Consultation is also available for family members, friends or professionals who are concerned about someone else s use of alcohol or drugs. Services are provided free of charge. All sessions are by appointment only. During scheduled group times we are unable to provide immediate appointments. If you are in crisis please call: Nova Vita (Emergency Shelter 24 hour crisis line) St. Leonard s (Community Service 24 hour crisis line) or Clients arriving at the agency under the influence of drugs or alcohol will have their appointment rescheduled. All services are confidential within the agency, with five exceptions listed below: While attending services with Brantford Native Housing, what you discuss with your counsellor and group leaders is private and confidential to the agency. Your counsellor/group leader cannot and will not freely share any information about you to others outside the agency. This means that you must give permission in writing in order for us to release information about you to anyone else. There are exceptions, required by law, where information may be given out without your consent. These include the following: Suspected child abuse or neglect will be reported to the Children s Aid Society of Brant; When someone is intending on harming him or herself (i.e. suicidal) or someone else (i.e. homicidal); A subpoena or summons is served by the courts; When a person arrives under the influence of alcohol or drugs and insists on driving, the Brantford Police Department will be notified if alternative arrangements are refused; and Brantford Native Housing Residential Support Addiction Program Application Page 11 of 13

12 Cases of medical emergencies, the ambulance/medical personnel will be provided with your name and emergency contact information. Under the Personal Health Information Protection Act (PHIPA) it is important for you to understand how your personal health information is protected and how it is used. All workers at Brantford Native Housing are aware of the sensitive nature of your health information and have received training in the Acts and are sworn to an Oath of Confidentiality. If you are concerned about how your personal health information is collected, used or disclosed, you may file a complaint against Brantford Native Housing or an individual, through the Information and Privacy Commissioner of Ontario. At Brantford Native Housing, an assigned Intake Worker or designated Program Worker will collect your information. From time to time, you may be accessing more than one program or service. This consent form will serve for all Brantford Native Housing programs you are currently accessing. Your original consent will be kept in your primary program file (the service you have the most contact with). only necessary information is collected about you; your information is only shared by written consent (with the noted exceptions); and storage, retention, and destruction of your personal health information complies with our file maintenance policy, legislation and privacy protection protocols. NOTE: From time to time this information may be used to do studies/ research/ reports on issues specific to the health of urban Aboriginal peoples and for the purpose of procuring additional funding. At no time will any identifiable information be processed for such use. By signing the consent section of this Client Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal and health information for the purposes listed. Should a new purpose arise, we shall seek your approval first. You may withdraw your consent at any time for the collection, use, or disclosure of your personal health information by providing notice to your primary worker within Brantford Native Housing. You also can place a condition or restriction on your consent, in that you may choose to restrict all or part of your health information from being shared. You also have the right to access your own personal health information, through a written request to the Manager, Community Programs. Brantford Native Housing Residential Support Addiction Program Application Page 12 of 13

13 CLIENT CONSENT 1. I have reviewed the preceding information and had it explained to me and /or the person who is my legal guardian; or has my power of attorney, where necessary; on how Brantford Native Housing will use my personal information and personal health information. 2. I am also aware of the steps taken by Brantford Native Housing to protect my information, when it is collected, used or disclosed, as well as how it will be stored and destroyed. 3. I agree that Brantford Native Housing can collect, use and disclose personal and personal health information about myself, or for my children under the age of 12 as their legal guardian; or I have power of attorney for their health; or they are my child/children as set out in the above information. Applicant Signature Date Witness Date Brantford Native Housing Residential Support Addiction Program Application Page 13 of 13

Grant House APPLICATION

Grant House APPLICATION Street Haven Addiction Services Grant House APPLICATION Dear applicant, We are pleased you are considering Grant House for treatment and hope in this package to provide more information about our program.

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

Crossroads Centre Inc. APPLICATION FOR ADMISSION. Telephone Contact Number: Health Card Number: Sex: M F

Crossroads Centre Inc. APPLICATION FOR ADMISSION. Telephone Contact Number: Health Card Number: Sex: M F Crossroads Centre Inc. APPLICATION FOR ADMISSION Name: Last Name First Name (s) Today s Date: Date of Birth: Telephone Contact Number: Who? Health Card Number: Sex: M F Please answer the following questions

More information

Dr. Bayla Schecter, Addictions Specialist Helen Brown, RN Intake Nurse Louise Hill, MSW Addiction Outpatient Treatment (Quadra Clinic) Coordinator

Dr. Bayla Schecter, Addictions Specialist Helen Brown, RN Intake Nurse Louise Hill, MSW Addiction Outpatient Treatment (Quadra Clinic) Coordinator Dr. Bayla Schecter, Addictions Specialist Helen Brown, RN Intake Nurse Louise Hill, MSW Addiction Outpatient p Treatment (Quadra Clinic) Coordinator VIHA Addiction Services Map (PH 250 213 4444) Does the

More information

JEWISH FAMILY SERVICE NOTICE OF PRIVACY PRACTICES

JEWISH FAMILY SERVICE NOTICE OF PRIVACY PRACTICES Jewish Family Service takes pride in treating our clients and each other with respect and dignity. Protecting your health information is very important to us. We want you to have a clear understanding

More information

New Port Centre. 5. DHQ Drug History Questionnaire 6. Adverse Consequences Questionnaire 7. Tracking Sheet With Scores of Other Provincial Assessments

New Port Centre. 5. DHQ Drug History Questionnaire 6. Adverse Consequences Questionnaire 7. Tracking Sheet With Scores of Other Provincial Assessments New Port Centre Page 1 of 2 NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) 378-4647 Ext 32500 Fax: (905) 834-3002 E-mail: NewPortAdmin@niagarahealth.on.ca

More information

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Patient Name (please print): Welcome to the therapy services

More information

Quality Management. Substance Abuse Outpatient Care Services Service Delivery Model. Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA)

Quality Management. Substance Abuse Outpatient Care Services Service Delivery Model. Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) Quality Management Substance Abuse Outpatient Care Services Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White

More information

Easy Does It, Inc. Transitional Housing Application

Easy Does It, Inc. Transitional Housing Application Easy Does It Inc. of Reading and Leesport Housing Programs Easy Does It, Inc. Transitional Housing Application Welcome Thank you for applying to Easy Does It, Inc. ( EDI ) a non-profit charitable organization

More information

SASKATCHEWAN NNADAP TREATMENT SERVICES APPLICATION FORM Revised June, 2009 VAN LOONVCONSULTING

SASKATCHEWAN NNADAP TREATMENT SERVICES APPLICATION FORM Revised June, 2009 VAN LOONVCONSULTING SASKATCHEWAN NNADAP TREATMENT SERVICES APPLICATION FORM Revised June, 2009 VAN LOONVCONSULTING This application is the first step required to pre-screen applicants for adult treatment at any of the NNADAP

More information

Chapter 388-877B WAC CHEMICAL DEPENDENCY SERVICES. Section One--Chemical Dependency--Detoxification Services

Chapter 388-877B WAC CHEMICAL DEPENDENCY SERVICES. Section One--Chemical Dependency--Detoxification Services Chapter 388-877B WAC CHEMICAL DEPENDENCY SERVICES Section One--Chemical Dependency--Detoxification Services WAC 388-877B-0100 Chemical dependency detoxification services--general. The rules in WAC 388-877B-0100

More information

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478

More information

NEW Inpatient Treatment Program Application Package

NEW Inpatient Treatment Program Application Package Health and Social Services December 11 th, 2008 MEMORANDUM TO: All Referral Professionals FROM: Dale Gordon Supervisor, Treatment Services Alcohol and Drug Services NEW Inpatient Treatment Program Application

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

More information

650 Clark Way Palo Alto, CA 94304 650.326.5530

650 Clark Way Palo Alto, CA 94304 650.326.5530 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. (Adopted 4-14-03; revised December 2006) If

More information

Welcome Letter - School Based Health Center

Welcome Letter - School Based Health Center Regional Alliance for Welcome Letter - School Based Health Center NOT A MEDICAL RECORD DOCUMENT Dear Student/Parent or Guardian: Regional Alliance for is unique school-based health centers providing services

More information

CATC Exam Practice Questions: 2015

CATC Exam Practice Questions: 2015 CATC Exam Practice Questions: 2015 These practice questions are included within the Certified Addictions Treatment Counselor (CATC) Examination Candidate Handbook, presented by California Association for

More information

Mino Ayaa Ta Win Helping Ourselves Heal

Mino Ayaa Ta Win Helping Ourselves Heal Fort Frances Tribal Health Area Health Services Inc. Behaviour Health Services P.O. Box 608, Fort Frances, Ontario, P9A3M9 Mino Ayaa Ta Win Helping Ourselves Heal Intake Form & Referral Package Pre-Treatment

More information

UTAH DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH SUBSTANCE USE DISORDER SERVICES MONITORING CHECKLIST (FY 2014) GENERAL PROGRAM REQUIREMENTS

UTAH DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH SUBSTANCE USE DISORDER SERVICES MONITORING CHECKLIST (FY 2014) GENERAL PROGRAM REQUIREMENTS UTAH DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH SUBSTANCE USE DISORDER SERVICES MONITORING CHECKLIST (FY 2014) Program Name Reviewer Name Date(s) of Review GENERAL PROGRAM REQUIREMENTS 2014 Division

More information

Columbia Addictions Center

Columbia Addictions Center Columbia Addictions Center Eileen Dewey, L.C.S.W.-C Director Date: Client Name: Date of Birth: Address: City: State: Zip: Home #: Cell #: E-mail: Preferred contact (circle one): home # cell # e-mail Emergency

More information

Choptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL

Choptank Community Health System Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Caroline County School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline County Public School system, your child has access to the School-Based

More information

Melanie Bierenbaum, Psy.D. Licensed Psychologist 3040 E. Cactus Rd, Suite A Phoenix, AZ 85032 Office: 602-769-2773

Melanie Bierenbaum, Psy.D. Licensed Psychologist 3040 E. Cactus Rd, Suite A Phoenix, AZ 85032 Office: 602-769-2773 Service Agreement and Treatment Consent Welcome and thank you for choosing to work with Dr. Bierenbaum. This document contains important information about professional services, the psychologist-patient

More information

Addictions Supportive Housing (ASH) Thames Valley 260-200 Queens Avenue London, Ontario N6A 1J3 Fax: 519-850-7330

Addictions Supportive Housing (ASH) Thames Valley 260-200 Queens Avenue London, Ontario N6A 1J3 Fax: 519-850-7330 Addictions Supportive Housing (ASH) Thames Valley 60-00 Queens Avenue London, Ontario N6A J Fax: 59-850-70 The purpose of this form is to provide initial entry for applicants into the ASH program. This

More information

APPLICATION FOR Page 1/7 RESIDENTIAL TREATMENT

APPLICATION FOR Page 1/7 RESIDENTIAL TREATMENT APPLICATION FOR Page 1/7 Instructions: The following form is required to begin the application process to Stonehenge. The form should be printed and completed by hand, then faxed or mailed to Stonehenge

More information

Kanawha Valley Fellowship Home

Kanawha Valley Fellowship Home Kanawha Valley Fellowship Home Client Assessment Form Date: Time: Assessment Taken Caller s Name: Agency (if applicable) Address: County: Relationship to Patient: Phone # Client s Name: Age: D.O.B.: Current

More information

MAT Disclosures & Consents 1 of 6. Authorization & Disclosure

MAT Disclosures & Consents 1 of 6. Authorization & Disclosure MAT Disclosures & Consents 1 of 6 Authorization & Disclosure ***YOUR INSURANCE MAY NOT PAY FOR ROUTINE SCREENING*** *** APPROPRIATE SCREENING DIAGNOSES MUST BE PROVIDED WHEN INDICATED*** Urine Drug Test

More information

Minor Rights: Access and Consent to Health Care

Minor Rights: Access and Consent to Health Care Minor Rights: Access and Consent to Health Care A resource for providers, parents and educators Not a legal document. This resource is intended to provide basic information about minors ability to consent

More information

Alcohol and Drug Abuse Treatment Centers

Alcohol and Drug Abuse Treatment Centers Division of State Operated Healthcare Facilities Alcohol and Drug Abuse Treatment Centers Jenny Wood Interim ADATC Team Leader HHS LOC Mental Health Subcommittee February 24, 2014 ADATC Locations R.J.

More information

HIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY

HIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. INTRODUCTION PLEASE REVIEW IT CAREFULLY Moriarty

More information

Floyd Healthcare Management, Inc. Notice of Privacy Practices

Floyd Healthcare Management, Inc. Notice of Privacy Practices Floyd Healthcare Management, Inc. 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

More information

Client s Rights and Counselor Responsibilities

Client s Rights and Counselor Responsibilities Client s Right to Give Informed Consent Client s Rights and Counselor Responsibilities Chapter 5 Psychology 475 Professional Ethics in Addictions Counseling Listen to the audio lecture while viewing these

More information

THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission.

THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission. THE SHEPHERD S INN Attention Intake Coordinator 156 Mills St, Atlanta, Georgia 30313 Phone: (404) 588-4015 Fax: (404) 215-9470 www.atlantamission.org PDP INTAKE APPLICATION Thank you for taking this important

More information

NOTICE OF PRIVACY PRACTICE

NOTICE OF PRIVACY PRACTICE Effective Date: September 23, 2013 NOTICE OF PRIVACY PRACTICE UNIVERSITY OF CALIFORNIA SAN FRANCISCO UCSF HEALTH SYSTEM THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

More information

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM DATE: CHART#: GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: ADDRESS: HOME PHONE: ADDRESS: CITY/STATE: ZIP CODE: **************************************************************************************

More information

Garland s Christian Counseling Center

Garland s Christian Counseling Center Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave

More information

Downloadable Forms: Otsego County Chemical Dependencies Clinic. Client Handbook. Revised 04/10

Downloadable Forms: Otsego County Chemical Dependencies Clinic. Client Handbook. Revised 04/10 Downloadable Forms: Otsego County Chemical Dependencies Clinic Client Handbook Revised 04/10 OTSEGO CHEMICAL DEPENDENCIES CLINIC 242 Main St, 2 nd Floor Oneonta, New York 13820 Tel. (607) 431-1030 Fax.

More information

Polk Medical Center Notice of Privacy Practices

Polk Medical Center Notice of Privacy Practices Polk Medical Center 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.

More information

AGREEMENT AND INFORMATION

AGREEMENT AND INFORMATION AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.

More information

Arrive 15 minutes before your scheduled appointment time.

Arrive 15 minutes before your scheduled appointment time. Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist

More information

Employed Full Time Student Part time student Patient s School Name / Employer School/Employer Address City State Zip

Employed Full Time Student Part time student Patient s School Name / Employer School/Employer Address City State Zip PATIENT INFORMATION DATE: Patient s Name Last First Middle Initial Patient s Address City State Zip Patient s Birth Date / / Male Female Age SS# Single Married Other May we call/leave message for appt.

More information

Notice of Privacy Practices

Notice of Privacy Practices SHANNON LERACH, Ph.D. Licensed Clinical Psychologist PSY23705 243 N. Highway 101, Suite 16, Solana Beach, CA 92075 Telephone: (619) 817.5320 Fax: (858) 481.1674 Notice of Privacy Practices This Notice

More information

Notice of Privacy Practices. Introduction

Notice of Privacy Practices. Introduction Notice of Privacy Practices Introduction At Ohio Valley Medical Center and East Ohio Regional Hospital, we are committed to using and disclosing protected health information about you responsibly. This

More information

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER***** SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDER UNIT Family Law Center Phone Number 817-884-1623 200 East Weatherford Street # 3040 Fax Number 817-212-7393 Fort Worth,

More information

UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM

UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home

More information

THE DIVISION OF ALCOHOL AND SUBSTANCE ABUSE. Chemical Dependency Treatment Options for Minors Under Age 18. A Guide for Parents

THE DIVISION OF ALCOHOL AND SUBSTANCE ABUSE. Chemical Dependency Treatment Options for Minors Under Age 18. A Guide for Parents THE DIVISION OF ALCOHOL AND SUBSTANCE ABUSE Chemical Dependency Treatment Options for Minors Under Age 18 A Guide for Parents Answers to Frequently Asked Questions September 2002 THE DIVISION OF ALCOHOL

More information

19 TH JUDICIAL ADULT DRUG COURT REFERRAL INFORMATION

19 TH JUDICIAL ADULT DRUG COURT REFERRAL INFORMATION 19 TH JUDICIAL ADULT DRUG COURT REFERRAL INFORMATION Please review the attached Drug Court contract and Authorization to Share Information. Once your case has been set on the adult drug court docket in

More information

Medical History Questionnaire

Medical History Questionnaire Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of

More information

Involuntary Mental Health Commitments

Involuntary Mental Health Commitments 3710 LANDMARK DRIVE, SUITE 208, COLUMBIA, SC 29204 (803) 782 0639; FAX (803) 790-1946 TOLL FREE IN SC: 1-866-275-7273 (VOICE) AND 1-866-232-4525 (TTY) E-mail: info@pandasc.org Website: www.pandasc.org

More information

Counseling Intake Form (Each person attending therapy should complete a form)

Counseling Intake Form (Each person attending therapy should complete a form) Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay

More information

PSYCHIATRIC INFORMATION: Currently in treatment? Yes No If no, what is barrier to treatment: Clinical Treatment Agency:

PSYCHIATRIC INFORMATION: Currently in treatment? Yes No If no, what is barrier to treatment: Clinical Treatment Agency: APPLICATION FOR CHILD AND YOUTH MENTAL HEALTH SUPPLEMENTARY SERVICES PROGRAM REQUESTED: Respite Services Supportive Intensive Home and Community-Based Case Management Case Management Services Waiver Referrals

More information

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER***** SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDERS Family Law Center Phone Number 817-884-1623 200 East Weatherford Street # 3040 Fax Number 817-212-7393 Fort Worth, Texas

More information

Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center

Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Intensive Outpatient Program Participant Handbook Table Of Contents: Welcome..... Page 1 Introduction. Page 1 Staff Page 1 Informed

More information

Borinquen Health Care Center 3601 Federal Highway Miami, FL (305)

Borinquen Health Care Center 3601 Federal Highway Miami, FL (305) Borinquen Health Care Center 3601 Federal Highway Miami, FL 33137 (305) 576-6611 NOTICE OF PRIVACY PRACTICES Effective Date: July 1, 2014 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

More information

Key Questions to Consider when Seeking Substance Abuse Treatment

Key Questions to Consider when Seeking Substance Abuse Treatment www.ccsa.ca www.cclt.ca Frequently Asked Questions Key Questions to Consider when Seeking Substance Abuse Treatment The Canadian Centre on Substance Abuse (CCSA) has developed this document to address

More information

Notice of Privacy Practices

Notice of Privacy Practices 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

More information

CONSENT FOR MEDICAL TREATMENT

CONSENT FOR MEDICAL TREATMENT CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern

More information

New Perspective Counseling Services Child/Teen Intake Form

New Perspective Counseling Services Child/Teen Intake Form Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.

More information

NOTICE OF PRIVACY PRACTICES. The University of North Carolina at Chapel Hill. UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates

NOTICE OF PRIVACY PRACTICES. The University of North Carolina at Chapel Hill. UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates NOTICE OF PRIVACY PRACTICES The University of North Carolina at Chapel Hill UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

More information

Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995

Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY

More information

INTAKE APPLICATION. MSH PDP Intake Application 090210 AUM Page 1 of 5

INTAKE APPLICATION. MSH PDP Intake Application 090210 AUM Page 1 of 5 MY SISTER S HOUSE Attention Intake Coordinator 921 Howell Mill Road NW, Atlanta, GA 30318 Phone: (404) 367-2476; Fax: (404) 875-6675.atlantamission.org INTAKE APPLICATION Thank you for taking this important

More information

NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS)

NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS) Effective Date: September 23, 2013 NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS) THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

More information

MAIL: Recovery Center Missoula FAX: 406 532 9901 1201 Wyoming St. OR ATTN: Admissions Missoula, MT 59801 ATTN: Admissions

MAIL: Recovery Center Missoula FAX: 406 532 9901 1201 Wyoming St. OR ATTN: Admissions Missoula, MT 59801 ATTN: Admissions Hello and thank you for your interest in Recovery Center Missoula. This letter serves to introduce our program to you, outline eligibility requirements, and describe the application/admission process.

More information

Adult Information Form Page 1

Adult Information Form Page 1 Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school

More information

St. Croix County Drug Court Program. Participant Handbook

St. Croix County Drug Court Program. Participant Handbook St. Croix County Drug Court Program Participant Handbook Updated: May 2014 To The St. Croix County Drug Court Program. This Handbook is designed to answer your questions and provide overall information

More information

RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES

RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES CHAPTER 0940-05-47 MINIMUM PROGRAM REQUIREMENTS FOR ALCOHOL AND DRUG OUTPATIENT DETOXIFICATION TREATMENT FACILITIES TABLE

More information

APPLICATION/ INFORMATION PACKAGE

APPLICATION/ INFORMATION PACKAGE APPLICATION/ INFORMATION PACKAGE We are glad that you are considering coming to LIFE Recovery. For your safety and well-being, we would like you to understand what our expectations are once you are admitted

More information

SUMMARY OF FINDINGS: OMF 2015 MEDICAL NEEDS ASSESSMENT

SUMMARY OF FINDINGS: OMF 2015 MEDICAL NEEDS ASSESSMENT SUMMARY OF FINDINGS: OMF 2015 MEDICAL NEEDS ASSESSMENT DEMOGRAPHICS Total surveys completed: 341 62 % Eastsound area 13 % Deer Harbor area 16 % Olga area 9 % Orcas Ferry area Age 2 % 25 34 8 % 35 44 13

More information

Rekindling House Dual Diagnosis Specialist

Rekindling House Dual Diagnosis Specialist Rekindling House Dual Diagnosis Specialist Tel: 01582 456 556 APPLICATION FOR TREATMENT Application Form / Comprehensive Assessment Form Please provide as much detail as you can it will help us process

More information

PATIENT TREATMENT AGREEMENT

PATIENT TREATMENT AGREEMENT PATIENT TREATMENT AGREEMENT Patient Name: : As a participant in buprenorphine treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment agreement as follows: I

More information

M ANHATTAN T REATMENT. Contents. Handbook. webready MTC. Guidelines and Program Information for Participants

M ANHATTAN T REATMENT. Contents. Handbook. webready MTC. Guidelines and Program Information for Participants M ANHATTAN T REATMENT C O U R T Welcome to MTC 3 What is MTC? 4 What s in it for me? 5 MTC Rules 6-8 STEP Phase Description and 9-14 Sanction Schedule Graduation 15 MTC Expectations 16-18 MTC Support Services

More information

Central Oklahoma Community Action agency

Central Oklahoma Community Action agency Central Oklahoma Community Action agency Norman Transitional Housing: Application/Intake Date: Are you a current or previous employee of Central Oklahoma Community Action Agency? Y or N 801 Chapel St.

More information

Treatment Approaches for Drug Addiction

Treatment Approaches for Drug Addiction Treatment Approaches for Drug Addiction [NOTE: This is a fact sheet covering research findings on effective treatment approaches for drug abuse and addiction. If you are seeking treatment, please call

More information

Performance Standards

Performance Standards Performance Standards Non-Hospital Rehabilitation Performance Standards are intended to provide a foundation and serve as a tool to promote continuous quality improvement and progression toward best practice

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE

More information

Rights for Individuals in Mental Health Facilities

Rights for Individuals in Mental Health Facilities HANDBOOK Rights for Individuals in Mental Health Facilities Admitted Under the Lanterman-Petris-Short Act C A L I F O R N I A D E P A R T M E N T O F Mental Health How to Reach Your Patients Rights Advocate

More information

REHAB XCEL, LLC. NEW PATIENT INFORMATION

REHAB XCEL, LLC. NEW PATIENT INFORMATION REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S

More information

Choptank Community Health System School Based Dental Program Healthy Children Are Better Learners DENTAL

Choptank Community Health System School Based Dental Program Healthy Children Are Better Learners DENTAL School Based Dental Program Healthy Children Are Better Learners DENTAL Dear Parent/Guardian: As a student in the Caroline, Dorchester and Talbot County Public School system, your child has access to the

More information

SUBSTANCE ABUSE OUTPATIENT

SUBSTANCE ABUSE OUTPATIENT SUBSTANCE ABUSE OUTPATIENT Service Category Description Substance abuse services - outpatient is the provision of medical or other treatment and/or counseling to address substance abuse problems (i.e.,

More information

Wairarapa Wellness. A brief overview of mental health and addiction services in Wairarapa.

Wairarapa Wellness. A brief overview of mental health and addiction services in Wairarapa. Wairarapa Wellness A brief overview of mental health and addiction services in Wairarapa. This brochure provides a general overview of the services Pathways, CareNZ and Workwise offer in the Wairarapa

More information

Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187

Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 F(808) 748-0778 OUTPATIENT SERVICES CONTRACT This document

More information

Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889

Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document

More information

Florida Alcohol and Drug Abuse Association. Presented to the Behavioral Health Quarterly Meeting Pensacola, Florida April 23, 2014

Florida Alcohol and Drug Abuse Association. Presented to the Behavioral Health Quarterly Meeting Pensacola, Florida April 23, 2014 Florida Alcohol and Drug Abuse Association Presented to the Behavioral Health Quarterly Meeting Pensacola, Florida April 23, 2014 Florida Alcohol and Drug Abuse Association Founded in 1981 Currently has

More information

PERSONAL RECOVERY PROGRAM INTAKE APPLICATION

PERSONAL RECOVERY PROGRAM INTAKE APPLICATION Attention: Intake Coordinator 1801 S. 35 th Ave Phoenix, AZ 85009 Phone: (602) 346-3360; Fax: (602) 233-1329 phoenixrescuemission.org PERSONAL RECOVERY PROGRAM INTAKE APPLICATION Thank you for taking this

More information

You will be secure, because there is hope. Job 11:18

You will be secure, because there is hope. Job 11:18 You will be secure, because there is hope. Job 11:18 The vision of Acres of Hope is to provide a safe family environment and a healthy living program for women with children that sets the foundation of

More information

McLean Ambulatory Treatment Center Adult Partial Hospital and Residential Program for Alcohol and Drug Abuse 115 Mill Street Belmont, MA 02478-9106

McLean Ambulatory Treatment Center Adult Partial Hospital and Residential Program for Alcohol and Drug Abuse 115 Mill Street Belmont, MA 02478-9106 Program Description Staffed by highly experienced psychiatrists, psychologists, social workers, nurses and addiction specialists, we are committed to working collaboratively with referring providers. Program

More information

Overview of Chemical Addictions Treatment. Psychology 470. Background

Overview of Chemical Addictions Treatment. Psychology 470. Background Overview of Chemical Addictions Treatment Psychology 470 Introduction to Chemical Additions Steven E. Meier, Ph.D. Listen to the audio lecture while viewing these slides 1 Background Treatment approaches

More information

CHEMICAL DEPENDENCE INPATIENT REHABILITATION SERVICES. [Statutory Authority: Mental Hygiene Law Sections 19.07(e), 19.09(b), 19.40, 32.01, 32.

CHEMICAL DEPENDENCE INPATIENT REHABILITATION SERVICES. [Statutory Authority: Mental Hygiene Law Sections 19.07(e), 19.09(b), 19.40, 32.01, 32. PART 818 CHEMICAL DEPENDENCE INPATIENT REHABILITATION SERVICES [Statutory Authority: Mental Hygiene Law Sections 19.07(e), 19.09(b), 19.40, 32.01, 32.07(a)] Notice: The following regulations are provided

More information

OUTPATIENT SERVICES CONTRACT

OUTPATIENT SERVICES CONTRACT OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

Psychiatric Residential Treatment Facility Referral

Psychiatric Residential Treatment Facility Referral Psychiatric Residential Treatment Facility Referral Date of referral: Psychiatric Residential Treatment Facility (PRTF) Referral Information Referral contact: Phone number: Referring facility/agency: Fax

More information

Nearest Relative Information (Not in same household)

Nearest Relative Information (Not in same household) Patient Information Name Male Female Address City State Zip Birth Date Age Responsible Party Information Name: Self Parent/Guardian Birth Date SSN# Drivers License# Email Employer Employer Phone# Employer

More information

Integrity Counseling & Coaching CLIENT INFORMATION FORM

Integrity Counseling & Coaching CLIENT INFORMATION FORM Integrity Counseling & Coaching CLIENT INFORMATION FORM NAME: DATE: ADDRESS: CITY: ZIP: HOME #: WORK #: CELL #: MAY WE LEAVE DISCREET MESSAGES AS NEEDED AT ABOVE LISTED NUMBERS? YES NO EMAIL: MAY WE CONTACT

More information

If you are under 18 years of age, your parents or guardian must sign for you and handle your privacy rights for you.

If you are under 18 years of age, your parents or guardian must sign for you and handle your privacy rights for you. HIPAA NOTICE OF PATIENT PRIVACY PRACTICES CWCC618 Exhibit A Effective Date: November 1, 2011 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

Mental Health Services in Durham Region

Mental Health Services in Durham Region Mental Health Services in Durham Region Table of Contents Crisis Supports and Services... 3 Mental Health Support and Counselling... 8 General Support and Counselling...13 Information Lines...20 Note:

More information

WHITE EARTH OSHKI MANIDOO CENTER

WHITE EARTH OSHKI MANIDOO CENTER ADMISSION FACE SHEET/CLIENT DEMOGRAPHICS CLIENT AND FAMILY INFORMATION check if release of information obtained from referring entity Admission : Admission Time: Discharge : Full Name: Nickname(s): SSN:

More information

Application for bail with electronic monitoring. Section 7(5) Bail Act 2000....[full name]..[address].[occupation] Applicant...

Application for bail with electronic monitoring. Section 7(5) Bail Act 2000....[full name]..[address].[occupation] Applicant... Application for bail with electronic monitoring Section 7(5) Bail Act 2000 In the District / High Court at:...........[full name]..[address].[occupation] Applicant This document is filed by: [name and

More information

BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES

BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established

More information

Client Rights Handbook. Your rights and responsibilities as a consumer of Access Family Services, Inc.

Client Rights Handbook. Your rights and responsibilities as a consumer of Access Family Services, Inc. Client Rights Handbook Your rights and responsibilities as a consumer of Access Family Services, Inc. Key Contacts Chief Executive Officer 704 521 4977 Chief Operating Officer 704 521 4977 President Southeastern

More information

University HealthCare Alliance

University HealthCare Alliance NOTICE OF PRIVACY PRACTICES University HealthCare Alliance Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.

More information

DISCLOSURE AND CONSENT FORM

DISCLOSURE AND CONSENT FORM 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

More information

HIPAA NOTICE OF PRIVACY PRACTICES

HIPAA NOTICE OF PRIVACY PRACTICES HIPAA NOTICE OF PRIVACY PRACTICES Marden Rehabilitation Associates, Inc. Marden Rehabilitation Associates of Ohio, Inc. Marden Rehabilitation Associates of West Virginia Health Care Plus Preferred Care

More information