Addiction Treatment Strategies

Patient Registration Legal Name First Middle Last Birth Date Address Street City State Zip Phone(s) Home Cell Work Is it ok to contact your cell? Yes No SSN Email (Used for appointment reminder) Known Allergies to Medication(s) Pharmacy Name & Phone Emergency Contact Relationship: Contact Phone(s) Home Cell Work How did you hear about Addiction Treatment Strategies? Signature Patient / Guarantor Date 1 P a g e

Privacy Practice Consent to Release/Receive Confidential Information By affixing my signature to this document I do hereby agree for Addiction Treatment Strategies to send/receive clinical information about my clinical, medical or legal status. The purpose of this disclosure is to monitor my progress in a plan of recovery from any illness(s) that has or could impair my ability to function to my maximum potential. The following information has been requested: Lab Results/UA Results Diagnosis and Treatment Recommendations Cooperation and Progress Identifying Information Change of Status Quarterly Progress Reports Psychological Reports Individual Treatment Plan Psychiatric Evaluation Other Information Requested from the Following: Name/Agency Address Fax Number Telephone Contact Person I understand that my records are protected under Federal confidentiality rules (42CFR Part 2). Federal Rules prohibit further disclosure of this information except by written consent of the person to whom it pertains. I may revoke this consent at any time except to the extent that there is a request from the courts (e.g. probation, parole, etc.) and that in any event this consent expires automatically as described below. Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. This consent expires six months after completion of the ATS program or as specified in writing by the patient. I further acknowledge that the information released was fully explained to me and this consent is given of my own free will. Signature: Date 2 P a g e

Acknowledgement and Consent for Treatment Phase 1 Program Welcome to Addiction Treatment Strategies. It is our intent to work with you to improve your mental health status so that you have better control of your life. In order for our intervention strategies to be successful it is essential that you feel comfortable in discussing your thoughts and feelings. Please be assured that ATS is extremely aware that successful treatment is contingent upon you feeling comfortable in discussing various facets of your life in strict confidence. We will not discuss your status as a patient with ATS unless: 1) you have given your informed written consent to share your clinical information with another person or healthcare provider. If we believe you have made a significant threat to harm yourself or another person, initially we will discuss our concerns with you then if necessary take appropriate action to prevent harm while maintaining confidentiality to the greatest extent possible; 2) we have reason to believe that you are going to cause serious harm to yourself or another person. We will develop a treatment plan in conjunction with your needs and our clinical intervention strategy. The treatment plan developed through ATS will be in a written format so that we can both review the direction of treatment as well as movement towards achieving your goals. You have a right to expect competent clinical intervention. If you are not satisfied with the direction and outcome of our program please let us know and we will provide you referrals to other programs. Throughout the six month treatment program we will continually review your progress, revise your treatment plan and redirect our energy to helping you meet your goals. ATS Phase 1 Program. Print Patient Name Patient Signature Date Witness Name Witness Signature Date 3 P a g e

CONSUMER RIGHTS AND RESPONSIBILITIES CONSUMER RIGHTS PURPOSE: To assure basic rights of consumers and to preserve independent expression and decision-making. AS A CONSUMER, I HAVE THE RIGHT TO: 1. the least restrictive treatment that is available and medically indicated, regardless of race, creed, sex, national origin, sexual orientation, socioeconomic status, language and religion/spiritual beliefs. 2. be treated with consideration, respect and full recognition of my dignity and individuality at all times and under all circumstances. This includes a professional relationship with all staff, free of psychological, physical, emotional abuse, neglect or humiliation. Any believed breach of ethics may be reported following grievance procedures. 3. confidentiality, within the law (see Privacy Practices) 4. request a change of your primary counselor 5. obtain from the primary therapist complete and current information concerning diagnosis (to the degree known), treatment, and any known prognosis. If there is a time that it is not clinically advisable to give such information to me, the information shall be made available to a legally authorized individual. 4 P a g e

CONSUMER RESPONSIBILITIES I HAVE THE RESPONSIBILITY FOR: 1. providing, to the best of my knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to my health. I must also report unexpected changes in my condition to the responsible program staff. 2. following the treatment plan recommended including completing my agreed upon goals before successful completion of the program. 3. keeping appointments and for notifying the proper persons if unable to do so. I understand that I am responsible to make up any missed sessions excused or not excused. I also understand that I am responsible for my own actions and for the consequences of my actions. I also understand that if there are three episodes of failure to keep scheduled appointments, I may be discharged from the program. 4. providing urine samples for the purposes of laboratory analysis upon request of clinical staff or according to court ordered agreement. I understand that the results of these tests will be incorporated into my medical record. 5. assuring that the financial obligations of my care are fulfilled; I am current on payment schedule. 6. following facility rules affecting my care, conduct and safety (including non-violent behavior, abstinence from drugs and/or alcohol). 7. being considerate of the rights of others. 5 P a g e

DISCHARGE POLICY: Discharge may occur under the following circumstances: Successful completion of the program. Gambling for money or any items of value, including substitute items. Use or possession of alcohol or other drugs on property or with other clients in the program. Acts of violence, threats, possession of weapons, or intimidation. Stealing or unauthorized use of the property. Violation of local, state, and federal laws. Failure to meet financial obligations. Selling/distributing illegal substances to patients in our program Every individual is unique as are the circumstances related to the above behaviors. Discharge is at the discretion of the treatment team. DRUG SCREENING AGREEMENT: Participation in the program reflects agreement to participate in periodic urine drug screens. Upon request of the staff, the consumer shall provide urine samples for the purpose of laboratory analysis. The results of these laboratory tests will be incorporated in the medical record at ATS and will remain confidential. The results of these tests will not be provided to outside parties without the express written consent of the client and will be used to help clinical staff in determining appropriate treatment plans. Results of urine drug screens may be discussed with your parents or guarantor, if in the opinion of the treatment team the results are a clinical issue. EQUAL OPPORTUNITY ATS provides equal opportunity to all individuals. No person shall be discriminated against because of race, color, religion, gender, sexual orientation, age, national origin, physical or mental handicap, or veteran status. Print Patient Name Patient Signature Date 6 P a g e

Fee/Payment Agreement Addiction Treatment Strategies Patients or guarantors may choose one of several options: ATS offers a six month program that may involve any or all of the following services appropriate to address your needs. During the assessment phase of treatment an individualized treatment plan will be developed with you to assist you in understanding the specifics of what will be expected during our six months of working together. At a minimum, our patients will receive a comprehensive evaluation by our medical director, drug/substance abuse evaluation, introduction and participation in Cognitive Behavior Therapy Groups and Individual counseling sessions. Option 1 = Make a one-time payment of $7500.00 Print Name Option 2 = Pay $8000.00 in 6 installments: Ist payment of $ 4000.00 due immediately to begin treatment. 30 days from start date 2nd payment due in the amount of $800. 60 days from start date 3rd payment due in the amount of $800. 90 days from start date 4th payment due in the amount of $800. 120 days from start date 5th payment due in the amount of $800. 180 days from start date 6th payment due in the amount of $800. I,, agree to have my Visa MasterCard Discover Print Name (circle one) credit card # exp date billing zip code charged according to the following payment schedule: 1st payment due on in the amount of $4000.00 2nd payment due on in the amount of $800. 3rd payment due on in the amount of $800. 4 th payment due on in the amount of $800 5 th payment due on in the amount of $800. 6 th payment due on in the amount of $800 Option 3 = Apply for a loan through Clark Behavioral Health Financing: Through our relationship with Clark patients can apply online for financial assistance. We can assist you with the process to determine if this is a viable option for your current situation. Option 4 = Apply for a loan through the Associated Bank of Glen Carbon: We have a working relationship with a local bank to assist you in obtaining an unsecured loan with the Associated Bank. Again, our staff can help you with the process. 7 P a g e

Regardless of the chosen option, patients are urged to contact their insurance carrier for out-of network benefit information including pre-authorization for outpatient addiction treatment for individual and group therapy sessions. ATS will submit insurance claims on your behalf for your participation in the ATS program. We will do this on a monthly basis and your reimbursement is contingent on the amount of services you receive through ATS. ATS will cover the initial medical evaluation as well as monthly medication visits by our physician. Any medical intervention above and beyond our usual and customary will be the financial responsibility of the patient and will be added to the monthly installment fee. This means if there is a need for additional detoxification procedures, additional visits required by your medical condition, or weekly visits mandated by the uniqueness of your situation, these will be billed at the usual and customary fee for each service. By signing this agreement, the patient/guarantor accepts the responsibility to pay for all services as explained to them and documented in the treatment plan. I understand that if I elect Option 2 (above) my credit card will be billed for the amount indicated on the date indicated. Patient or Guarantor Signature Date Staff Signature Date (Person responsible for payment) 8 P a g e

Group Information Do: 1. Be respectful of others. 2. Be responsible for participating. No participation equals no progress. 3. Practice confidentiality. Process your feelings about group in group and with the counselor. Do not discuss details, names, etc., outside group. 4. Practice H.O.W.; being honest, open-minded, and willing. 5. Practice authenticity; showing all sides of your personality. 6. This is your group and your therapy -- If it s not moving in the direction you would like for it to move, express your opinion. 7. Keep your sharing personal. Make I statements. ( I feel when because ). ( I want. ). 8. Keep confrontations, concerns, specific rather than general, i.e., Some people, everyone. 9. Take emotional risks ---- Growth occurs by going beyond your limits. 10. Offer to give feedback to others. Request and accept feedback from others. 11. Focus on Here and Now. Share how thoughts of past or future affect you today. 12. Make eye contact when speaking to your group member. Print Patient Name Patient Signature Date 9 P a g e

Insurance Information Patient s name (last) (first) (middle initial) Patient s Address: Patient s Phone number:_( ) Birth date: Employer: Insurance Company: Policy # or Group # Patient s Insurance I.D. #: I authorize the release of any medical or other information necessary to process the insurance claim. Patient s Signature Date If insurance is provided by another, please complete the next section: Insured s name (last) (first) (middle initial) Insured s Address: Insured s Phone number:_( ) Birth date: Insured s Employer: Insured s Insurance I.D. #: Patient s relationship to insured: I authorized payment of medical benefits to the supplier for services. Insured s Signature Date 10 P a g e