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Revised 2.2016//reviewed 8.2016
CLIENT ORIENTATION (Child/Adolescent & Parent/Guardian)
WELCOME to Ann Arbor Consultation Services, Inc.
OVERVIEW OF YOUR FIRST VISIT. During your first visit, you and your child/adolescent will meet with
a mental health clinician (social worker, psychologist, counselor, etc.) for 45 minutes to one hour. Please note
that our clinicians vary in their approach to assessment (e.g., who is seen first, et cetera) but all will include both
you and your child, as appropriate (your therapist and/or our staff can review certain exceptions), in assessment,
planning, and treatment. The goals of the first visit are:
(1) the clinician determining a mental health diagnosis, if applicable, based on the information provided
during the meeting and via your completed paperwork;
(2) review of your treatment goals, taking into account your child/adolescent’s strengths, abilities,
treatment preferences and needs, as well as your preferences in this regard
(3) review of your child/adolescent’s options for treatment, including types of therapy, psychiatry
medication referral, and outside options (support groups, etc), and
(4) beginning to write a jointly-developed treatment plan.
It is not always possible to complete all of these tasks in the time allotted and they may need to be continued at
your next visit(s). Of course, treatment is an ongoing process and your child/adolescent’s treatment goals will
likely change over time. Every 90 days your therapist will review your child/adolescent’s progress with you
(and your child/adolescent) to determine how well therapy and other strategies are working; you will develop
new goals or continue current goals at that time.
OVERVIEW OF THERAPY AT AACS. Our goal is to provide collaborative, evidence-informed, short-term
mental health treatment. Your therapist will be your primary point of contact and “care coordinator.” Length
of treatment varies depending on several factors, including your diagnosis and other factors. On average clients
are seen at AACS for 8 to 10 sessions, with a good proportion being seen for 12 to 16 visits or sometimes more.
Your therapist will try to estimate, when possible, how long she/he expects your child/adolescent to be in
treatment. Sometimes trials of different types of therapy may be needed, just like people try different
medications. If your child/adolescent sees a psychiatrist or NP at AACS, your therapist will provide an
overview of their services and what to expect when they give you the referral information. Finally, please note
that your child/adolescent, and perhaps you as well as their guardian, will usually be asked to complete
(generally very short) questionnaires at every session that will assist your therapist with measuring your
child/adolescent’s progress towards treatment goals.
MATCH WITH YOUR THERAPIST. This is very important to us; recent research indicates this is an
important piece of positive therapy outcome. Please see our Tips for Success in therapy handout for additional
information about this as well as other determinants of therapy success.
EMERGENCY PROCEDURES. Please take note of the emergency exits posted in the waiting area, as well as
the posted notices of fire extinguishers and first aid supplies.
URGENT ISSUES. If at any time during your child/adolescent’s stay at AACS you have an urgent issue that
must be addressed right away and it is between 8am-5pm on a weekday, please contact the main office at (734)
996-9111 ext 0 for assistance. If it is after 5 pm on a weekday, or a weekend/holiday, please contact the after-
hours Answering Service by dialing (734) 996-9111 and waiting for the Answering Service Prompt. The
Revised 3.2017/reviewed 8.2016
Answering Service can also be reached directly at (734) 337-2116. If your child/teen has a life-threatening
emergency, please proceed to the emergency room.
APPOINTMENTS. All appointments with your child/teen’s therapist are made with that therapist, via their
voicemail extension. Appointments with psychiatry at AACS are made in a different manner; your therapist
will provide instructions if they make a referral for you. Waiting for appointments If you do not see anyone
in the reception office, please feel free to ask any staff member for assistance if needed. If you have been
waiting longer than 12 minutes past the time of your regularly scheduled appointment, please tell any staff
person (including therapists or psychiatrists). Please note that the Stadium and Brighton locations do not have
front office staff.
FAMILY INVOLVEMENT IN TREATMENT. In general, family involvement in treatment of a child or teen is considered important. Your therapist or psychiatrist will make suggestions regarding how family can best be involved, taking preferences and needs into account. Please note that we also have a Family Tip Sheet as well as a Caregiver Tip Sheet that family members and friends can review - it contains various suggestions about how they can help. Finally, please also review our child/adolescent therapy contract for important information.
ADDITIONAL IMPORTANT INFORMATION. Please note that tobacco use and drug/alcohol use are
strictly prohibited on the premises; bringing and/or using illegal substances is also prohibited. You may bring
legal substances, including prescribed and over-the-counter medications, with you to our clinic, but must keep them within your possession at all times. Please also note that AACS staff will NOT use seclusion or restraint
in dealing with a client or family member. However, violence or threatening behavior, possession of a
weapon, or intoxication will result in exclusion from our services and may require us to contact the police.
CONSUMER HANDBOOK. Please see the AACS Consumer Handbook available in the waiting area at each
location or via our website (a2consultation.com in the Forms section) for important additional information
regarding our services. The AACS Consumer Handbook contains a copy of our HIPAA Privacy Policies and
our recipient rights brochure (copies of these are also located in our initial client paperwork packet). The
Consumer Handbook also contains a list of our services and staff, our mission statement, information on
procedures to follow to obtain copies of your records, a copy of our complaints policy and grievance/appeal
procedures, a description of our psychiatric services, and our admission/discharge/readmission criteria, as well as other important information. It also contains a list of helpful resources and support groups in the area. You
have the right to request copies of any of the information located in the Consumer Handbook.
QUESTIONS AND OTHER INPUT. If you have questions about any of the information above, please ask your therapist, psychiatrist, or another staff person. If you would like to give general feedback, please visit our website (a2consultation.com) and click the feedback link on the homepage. Alternatively, you can send a message via mail to our headquarters (5331 Plymouth Rd, Ann Arbor MI 48105). If you have a complaint, please contact one of our Clinical Co-Directors, Karen Bowersox, PhD, or Terry Dunivin, LMSW, or our Stadium Site Manager Anne Carlson, PsyD. All three can be reached via our Main Office at (734) 996-9111 ext 0. If you have a question about your Rights, or you feel a complaint has not been resolved to your satisfaction,please contact our Recipient Rights Officer, Karen Bowersox, PhD at (734) 996-9111 ext 0. Substance useprogram clients may also speak with the Substance Use Program Rights Officer, Karen Bowersox, PhD, (734)996-9111 ext 0.
55333311 PPllyymmoouutthh RRdd PPHHOONNEE ((773344)) 999966--99111111AANNNN AARRBBOORR,, MMII 4488110055 FFAAXX ((773344)) 999966--11995500
CCOONNFFIIRRMMAATTIIOONN OOFF LLEEGGAALL CCUUSSTTOODDYY
***ONLY FILL OUT THIS FORM IF BOTH PARENTS DO NOT LIVE IN THE SAME RESIDENCE AS THE CHILD
CHECK THIS BOX IF THIS FORM IS NOT APPLICABLE TO YOUR CHILD
Sole Legal Custodial Parent
Joint Legal Custodial Parent
Legal Guardian
of (child) _______________________________ and therefore I have the legal authority to enter this
child into therapy and to sign papers on the child’s behalf. I understand that if there is joint legal
custody with another person, that person may also be involved in the child’s therapy and/or may
receive communication from the therapist.
___________________________________________ ______________
Legal Custodial Parent or Guardian Date
If Joint Legal Custody, please provide the following information:
Name of other parent or guardian: ____________________________________________________
Address: _____________________________________
_____________________________________
_____________________________________
Phone(s): ________________________ ______________________
REVISED 8.10.2006//reviewed 8.2016
ann arbor
servicesonsultationC
Ann Arbor Consultation Services 5331 Plymouth Road Ann Arbor MI 48105 Phone (734) 996-9111 Fax (734) 996-1950
www.a2consultation.com
Release of Information to Primary Care Physician I, _________________________________ hereby DO* DO NOT authorize Ann Arbor Consultation
(CLIENT NAME) (CHECK ONE) Services (AACS) to release information contained in my record to my Primary Care Physician (PCP) and for my PCP to release information to the psychiatry service at AACS. If consent is provided, information will be released as follows:
1. Type of Information to be disclosed: assessment &/or treatment information _2. This consent is subject to revocation at any time except to the extent that the program which is to
make the disclosure has already taken action in reliance upon this release (i.e., we are not responsible forinformation released prior to revocation). If consent is not voided then this release will terminate on:A. Event: ____6 months after date of my discharge from Ann Arbor Consultation Services__________B. Date and/or Condition: ___________________________________________________________
___________________________________________ __________________________________________ Witness Date Client Signature (or parent/guardian) Date *I understand that my consent to release information will include sending of the information below to my PCP, as well as treatment updates, discharge information (e.g. a summaryof my treatment) and any other information deemed necessary to coordinate my treatment at Ann Arbor Consultation Services. I understand that this release is reciprocal, meaning that it also permits my PCP to send/communicate information to Ann Arbor Consultation Services.
Communication to Primary Care Physician
Name of Patient: _____________________________________________________(DOB)_____________________ PLEASE PRINT
Dr: _____________________________________________________________ Phone: ______________________
Address: ________________________________________________________ Fax: ________________________
AACS USE ONLY Date of Assessment ______/_______/______ DSM-5 Diagnosis: __________________________
Key Symptoms:________________________________________________________________________________
Other notable findings (risk, history, mental status):____________________________________________________ ____________________________________________________________________________________________ Behavioral Health Treatment Plan Information Type of therapy ☐CBT (Cognitive Behavioral Therapy) ☐Mindfulness ☐Other___________________________
☐IPT (Interpersonal Therapy) ☐Dynamic Therapy ☐DBT (Dialectical Behavior Therapy) Modality ☐Individual ☐Group ☐Couples ☐Family Frequency ☐Weekly ☐Biweekly ☐ _____________ Estimated Treatment Completion Date ____/_____/____ Psychiatric Management Current Medications__________________________________________________________________________________________________________________________RX by:_________________ ☐Patient has been referred to the psychiatric service at our clinic (consult report forthcoming)☐Patient has been referred to you for initial &/or continued treatment with psychiatric medication(s)☐Declined referral for psychiatric medication treatment☐Patient will attempt behavioral health interventions before a psychiatric medication trial
Additional member-specific recommendations made (PCP visits, etc):_____________________________
____________________________________________________________________________________________ Please contact me with any questions or comments ☐ Mailed ☐ Faxed on _____(PHQ Included? ☐ Y ☐ N)
(DATE)
__________________________________________x_________ ________________________________ Behavioral Health Provider (Name, Credentials) EXT Signature
Under federal and state law, re-disclosure of this information may require the authorization of the patient to whom the information pertains, or his/her personal representative (e.g., legal guardian, parent of a minor child). Please consider the need for written authorization before you re-disclose any of this information.
3.2017/reviewed 1.2015
Ann Arbor Consultation Services: CONSENT TO TREATMENT AND DIAGNOSTIC SERVICES
Client _____________________________________________________________________________________ General Information I understand that the services I and/or my dependent will receive at Ann Arbor Consultation Services (AACS) are based on currently accepted practice in the fields of mental health and/or substance use disorder diagnosis and treatment. I also understand that the outcome of treatment cannot be guaranteed and that services continue with my voluntary consent. I understand that I can withdraw my consent and discontinue treatment at any time. I agree to provide accurate information to my providers for the development and achievement of treatment plan goals. Risks of Therapy I understand that therapy has potential emotional risks. Approaching feelings or thoughts that I have tried not to think about may be painful. Making changes in my thinking or behaviors can be scary and sometimes disruptive to my relationships. I understand these risks and that I need to carefully consider whether these risks are worth the benefits of change. I understand that most people who take these risks find that therapy is helpful. Using Insurance for Services I understand that in choosing to use my insurance for services at AACS, I give AACS permission to bill my insurance company for services rendered to me or my dependent(s) and to release any information such as diagnosis, treatment plans, and Protected Health Information as necessary to obtain payment for services. I agree to disclose all relevant and current insurance information both completely and accurately including any changes to my insurance coverage. I understand that it is my responsibility to understand my insurance benefits, including limitations and/or exclusions, copays, yearly maximums, and authorizations for treatment as applicable. AACS staff may try to help me navigate my insurance benefits, but ultimately I am responsible for understanding my benefits. Cancelled/Missed Appointments and Associated Fees I understand that it is AACS policy and the policy of my therapist as an independent contractor of AACS, to charge me for any appointment in which I fail to attend or fail to provide at least 24 hours notice of cancellation. If I miss any appointment with the psychiatric provider I will be charged the full fee with no exceptions. I will be charged up to $230 for a missed appointment or late cancellation depending upon the type of appointment. I understand that insurance companies will not pay for any missed appointment and any appointment that is missed without giving 24 hours notice will be billed directly to me. I understand that payment for a missed or late cancelled appointment is due prior to my next appointment. Fees for Services Rendered I understand that out of pocket expenses that are not covered by my insurance company are my responsibility to pay and fees for services including copays are to be paid at the time of the service. It is not AACS policy to send out statements for unpaid copays. If my insurance company does not cover any fees for the services my dependent(s) or I have received through AACS, I accept responsibility for these costs. If maximum insurance benefits have been reached, I will be fully responsible for any fees for services subsequently rendered to my dependent(s) or myself. I understand that many insurance companies do not cover two mental health appointments on the same day and that I will be charged directly for one of the two appointments if this occurs (e.g., meeting with a therapist and
psychiatry provider in the same day.) If a diagnostic evaluation or treatment is terminated by choice or because of a violation of program rules, I agree to pay all outstanding fees existing at the time of termination. I understand that telephone consultations over 5 minutes may be subject to a charge, which my insurance will not cover. I understand I will be made aware of any potential fees for this service and will have the opportunity to consent to receiving these services. A fee schedule for these expenses can be obtained from my therapist. Fees Due in Advance of Certain Services I understand that some services provided by AACS clinicians are not covered by insurance. I understand that fees for these services must be paid in advance. These billable services include: School visits, letter preparation, court visits, and copying records. I understand that I will be made aware of any of these potential fees before I incur any charges and will be provided the opportunity to consent to receiving these services. A fee schedule for these expenses can be obtained from my therapist. Unpaid Balances I understand that unpaid balances over $200 and/or over 90 days old will automatically be transferred to a collection agency unless formal payment arrangements have been made with the AACS billing department. I understand that defaulting on any payment arrangement will lead to my account going immediately back into a collection status. I understand that treatment could be suspended or terminated for nonpayment. Psychiatric Services I recognize that in order for services to be provided to me or my dependent, I may be asked to consult with a psychiatric provider at AACS when this is considered necessary by the clinical staff. I understand that I also may ask to consult with a psychiatric provider on staff if I consider this necessary. I understand that I need to be actively engaging in therapy to receive psychiatric services at AACS. If therapy is discontinued for any reason at AACS, I understand that my psychiatric care will be transferred to my Primary Care Physician or other community psychiatric provider. I understand that once I am stable on my medications, my psychiatric provider will refer me to my Primary Care Physician or other community provider for follow up care even if I am still in therapy at AACS. I understand that services at AACS are for clinical treatment purposes only. Psychiatric disability, custody, and other forensic evaluation services are not a part of the scope of services and are therefore not provided. Confidentiality and Records Release I understand that my records or the records of my dependent(s) are confidential under the law and may be released only as allowed under existing applicable statutes. (Please see page 4 of this document for confidentiality specific to alcohol and drug use disorder client information.) I understand that AACS program staff may release client information without client consent under the following conditions:
● If the client threatens to harm him/herself or others ● If the staff suspect child or elder abuse or neglect ● To medical personnel to handle a medical emergency ● Under a court order or subpoena
Contact by AACS I understand that it may be necessary for AACS to contact me by mail or telephone during or after my dependent’s or my treatment for the purpose of confirming or scheduling appointments, rectifying billing and payment issues, completing forms, conducting surveys, or any other necessary follow-up. I understand that I have the right to request contact and/or confidential information by alternative means, at a different location, as specified in the Notice of Privacy Practices.
Recipient Rights I understand that as a recipient of counseling services, I have received a description of my rights. I understand that I can contact the Recipient Rights Advisor anytime I believe my rights have been violated. I acknowledge that I received a copy of my rights at my dependent’s or my intake appointment. AACS’s Recipient Rights Advisor is Karen Bowersox, Ph.D. and can be reached at 734-996-9111 ext.0. Additional Program Rules I understand that if I am violent, verbally or physically threaten, or harass my provider or any AACS provider or staff member, I will be terminated unilaterally and immediately from treatment. I understand that possession of a weapon on clinic property is prohibited. I understand that I will be refused an appointment on any day that I come to the clinic intoxicated and I would not be allowed to drive myself in that situation. I understand that AACS never uses seclusion or restraint. I understand that should custodial parents disagree regarding treatment, or if anyone requests AACS clinicians to get involved in a legal dispute, therapy may be suspended or terminated. (Please refer to the “Child/Adolescent Therapy Contract”.) I understand that nonadherence to the treatment plan or recommended treatment may result in termination of treatment. I understand that I have the right to appeal a termination from treatment to the Recipient Rights Advisor, within 15 days of when such action occurs.
My signature below acknowledges that I am voluntarily authorizing diagnostic and treatment services at AACS for myself and/or my dependent(s). I recognize that I may refuse any aspect of treatment. I also accept that such a refusal may, in some instances, result in termination of services by AACS.
I understand that AACS therapists and psychiatry providers are independent contractors using AACS offices, billing services, and record keeping facilities and the therapists and psychiatry providers are not employees of AACS.
My signature below acknowledges that I have read this Consent to Treatment, that I agree to abide by the policies and procedures of AACS as outlined above, and that I have received copies of the Recipient Rights brochure and Notice of Privacy Practices. I am aware that the AACS Consumer Handbook (located in the waiting area) contains additional information about AACS services and policies, and that I may request my own copies of the materials in the Consumer Handbook.
___________________________________ ______________________ Signature of Client or Parent/Guardian Date ___________________________________ ______________________ Signature of Witness Date
CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE CLIENT INFORMATION
All clients: Please sign this form at the bottom. Only check the box below if the statement by the box is applicable to you. ▢ I am not at AACS for alcohol or drug use disorder services and therefore this form is not applicable to me. The confidentiality of alcohol and drug abuse client records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a client attends the program, or disclose any information identifying a client as an alcohol or drug abuser, unless:
(1) The client consents in writing; OR (2) The disclosure is allowed by a court order; OR (3) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for
research, audit, or program evaluation; OR (4) The person commits or threatens to commit a crime either at the program or against any person who
works for the program. Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs. Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. (See 42 U.S.C. § 290dd-2 for federal law and 42 C.F.R. Part 2 for federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records.) ___________________________________ ______________________ Signature of Client or Parent/Guardian Date ___________________________________ ______________________ Signature of Witness Date
CHILD/ADOLESCENT THERAPY CONTRACT Child’s Name________________________________
Welcome to our practice. Before your child begins treatment, it is important to review some common child therapy guidelines.* These guidelines have been developed to help me to treat your child. Your signature below indicates that you have reviewed these guidelines and agree to follow them.
● If legal custody is shared, both parents must consent to treatment of your child. If either custodial parent objectsto your child’s participation in therapy, we must end treatment.
● It is in your child’s best interest for therapy to be uninterrupted. To ensure that therapy is not interrupted dueto nonpayment of your child’s bill (copays, fees, etc) it is our clinic’s policy that whoever signs the Consent to Treatment is responsible for bill payment regardless of other circumstances (divorce decree, etc).
● I may require parents, stepparents, or co-parents to be substantially involved in treatment. We will discuss theways in which I will need you to be involved after I have assessed your child’s situation. We will work together in a collaborative manner, although there may be times that I will make specific requests of you related to your child’s treatment. I will need you to follow-through with those requests as well as keep me informed of relevant events in your family’s/child’s life.
● The parents, stepparents, or co-parents of children in therapy often have conflicts. To best treat your child I willgenerally avoid taking sides in these conflicts unless it will benefit your child. Taking sides usually compromises my role as your child’s therapist.
● Most things you tell me are confidential (please review the exceptions in the Consent to Treatment). Eachcustodial parent will have the same access to give and receive information as long as contracted obligations and policies are met.
● If necessary to protect the life of your child or another person, I have the option of disclosing information to youwithout your child’s consent (please review our Consent to Treatment).
● If treatment ends, I have the option of having a few closing sessions with your child to properly end the treatmentrelationship.
● I will inform you if your child does not attend treatment sessions.● Periodically during treatment and at the end of treatment, I will review the progress we have made towards goals
and potential areas that may require intervention in the future.● To work effectively with your child, I need you to agree that my role will be limited to providing treatment.
This means that you agree to not involve me in any legal matters, including disputes about custody or custodyarrangements (visitation, etc.). If there is a court-appointed evaluator, and if appropriate releases are signedand a court order is provided, I will provide general information about your child which will not includerecommendations concerning custody or custody arrangements. I am ethically bound not to give my opinionabout either parent’s custody or visitation suitability because I was hired to provide therapy, not a custodyevaluation.
● If, for any reason, I am ordered to appear as a witness, the party responsible for my participation agrees toreimburse me at the rate of $200 per hour for time spent traveling, preparing reports, testifying, being inattendance, and any other case-related costs.
__________________________________________Parent/Guardian Name & Signature Date
__________________________________________Clinician Name & Signature Date
___________________________________________Parent/Guardian Name & Signature Date
*Adapted from the American Psychological Association’s Guidelines for Child/Adolescent Therapy Initial Version 6.16.2011/reviewed 8.2016
AACS Patient ID#_____________________
BILLING and/or INSURANCE INFORMATION CLIENT: PLEASE PRINT
THERAPIST USE ONLY
THERAPIST_____________________________
DSM-5_________________________________
COPAY___________MH SA
CLIENT INFORMATION
CLIENT NAME___________________________________________
ADDRESS_______________________________________________
_______________________________________________________
CITY__________________________________________________
STATE __________________________ ZIP CODE______________
HOME PHONE (_________)________________________________
WORK PHONE (_________)_________________________________
OTHER PHONE(_________)________________________________
EMAIL ___________________________________________________
DATE OF BIRTH____________________________________________
MALE FEMALE
SOCIAL SECURITY #________________________________________
MARITAL STATUS__________________________________________
EMPLOYER_______________________________________________
PRIMARY PHYSICIAN_______________________________________
REFERRED BY_____________________________________________
RESPONSIBLE PARTY / PARENT OR GUARDIAN INFORMATION THIS SECTION MUST BE COMPLETED IF CLIENT IS UNDER 18 YEARS OF AGE. THIS PERSON WILL RECEIVE ANY BILLS ACCRUED AT AACS
NAME__________________________________________________
ADDRESS_______________________________________________
_______________________________________________________
CITY__________________________________________________
STATE __________________________ ZIP CODE______________
HOME PHONE (_________)________________________________
WORK PHONE (_________)_________________________________
OTHER PHONE(_________)_________________________________
EMAIL ADDRESS_________________________________________
DATE OF BIRTH___________________________________________
MALE FEMALE
SOCIAL SECURITY #________________________________________
EMPLOYER______________________________________________
EAP / CAP / AAP INFORMATION COMPLETE IF USING YOUR EAP EMAIL CONTACT EMPLOYER______________________________________________
EMPLOYEE______________________________________________
RELATIONSHIP TO CLIENT__________________________________
I DO DO NOT GRANT PERMISSION FOR AACS TO SEND ME INFORMATION (EG, NEWSLETTERS, CLINIC INFORMATION, ETC) VIA EMAIL please initial here:_____________
PRIMARY INSURANCE INFORMATION
INSURANCE COMPANY___________________________________
CONTRACT #___________________________________________
GROUP #______________________________________________
EMPLOYER_____________________________________________
POLICY HOLDER___________________________________________
SOCIAL SECURITY #_________________________________________
DATE OF BIRTH____________________________________________
RELATIONSHIP TO CLIENT____________________________________
SECONDARY INSURANCE INFORMATION
INSURANCE COMPANY__________________________________
CONTRACT #__________________________________________
GROUP #______________________________________________
EMPLOYER____________________________________________
_
POLICY HOLDER___________________________________________
SOCIAL SECURITY #_________________________________________
DATE OF BIRTH____________________________________________
RELATIONSHIP TO CLIENT____________________________________
I HAVE RECEIVED A COPY OF “KNOW YOUR RIGHTS” WHICH EXPLAINS MY RIGHTS AS A CLIENT IN THE STATE OF MICHIGAN
EMERGENCY CONTACT INFORMATION
SAME AS GUARDIAN ABOVE or NAME_______________________RELATIONSHIP______________ PHONE__________________________
SIGNATURE________________________________________________________ DATE____________________________12.2015 /reviewed 8.2016
(ICD-10)
8.2.2011/reviewed 8.2016
Medicaid Waiver
I, _______________________________ understand that Ann Arbor Consultation Services does Guardian name
not participate in Medicaid. My signature below indicates that _________________________ Child/Adolescent’s Name
does not have Medicaid coverage.
I understand that if this changes and the child/adolescent becomes a participant with
Medicaid, it is my responsibility to inform his/her clinician immediately. Because AACS does not
participate with Medicaid, I understand that if the child/adolescent obtains Medicaid coverage I will
be responsible for paying the full fee of any sessions that occur while he/she has Medicaid coverage
(up to $200 for an initial visit and up to $135 for a return visit). I understand that the
child/adolescent can no longer be seen at AACS if he/she has Medicaid. If the child/adolescent
becomes a Medicaid participant he/she will be discharged from care at AACS
____________________________________ _________________________________ Parent/Guardian Signature Date Clinician Signature Date
Client Name _______________________________________________ Revised 1.12.2015//reviewed 8.2016
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/violence/sexual assault
Copyright © 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.
DSM-5 Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 6–17
Date:___________ Child’s Name: _________________________________
Relationship with the child: _________________________________________________________________
Instructions (to the parent or guardian of child): The questions below ask about things that might have bothered your child. For each question, circle the number that best describes how much (or how often) your child has been bothered by each problem during the past TWO (2) WEEKS.
During the past TWO (2) WEEKS, how much (or how often) has your child…
None Not at
all
Slight Rare, less than a day
or two
Mild Several
days
Moderate More than
half the days
Severe Nearly every day
Highest Domain
Score (clinician)
I. 1. Complained of stomachaches, headaches, or other aches and pains? 0 1 2 3 4
2. Said he/she was worried about his/her health or about getting sick? 0 1 2 3 4
II. 3.
Had problems sleeping—that is, trouble falling asleep, staying asleep, or waking up too early?
0 1 2 3 4
III. 4.
Had problems paying attention when he/she was in class or doing his/her homework or reading a book or playing a game?
0 1 2 3 4
IV. 5. Had less fun doing things than he/she used to? 0 1 2 3 4
6. Seemed sad or depressed for several hours? 0 1 2 3 4
V. &
VI.
7. Seemed more irritated or easily annoyed than usual? 0 1 2 3 4
8. Seemed angry or lost his/her temper? 0 1 2 3 4
VII. 9. Started lots more projects than usual or did more risky things than usual? 0 1 2 3 4
10. Slept less than usual for him/her, but still had lots of energy? 0 1 2 3 4
VIII. 11. Said he/she felt nervous, anxious, or scared? 0 1 2 3 4
12. Not been able to stop worrying? 0 1 2 3 4
13. Said he/she couldn’t do things he/she wanted to or should have done, because they made him/her feel nervous?
0 1 2 3 4
IX. 14.
Said that he/she heard voices—when there was no one there—speaking about him/her or telling him/her what to do or saying bad things to him/her?
0 1 2 3 4
15. Said that he/she had a vision when he/she was completely awake—that is, saw something or someone that no one else could see?
0 1 2 3 4
X. 16.
Said that he/she had thoughts that kept coming into his/her mind that he/she would do something bad or that something bad would happen to him/her or to someone else?
0 1 2 3 4
17. Said he/she felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off?
0 1 2 3 4
18. Seemed to worry a lot about things he/she touched being dirty or having germs or being poisoned?
0 1 2 3 4
19. Said that he/she had to do things in a certain way, like counting or saying special things out loud, in order to keep something bad from happening?
0 1 2 3 4
In the past TWO (2) WEEKS, has your child …
XI. 20. Had an alcoholic beverage (beer, wine, liquor, etc.)? Yes No Don’t Know
21. Smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco? Yes No Don’t Know
22. Used drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?
Yes No Don’t Know
23. Used any medicine without a doctor’s prescription (e.g., painkillers [like Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers [like sleeping pills or Valium], or steroids)?
Yes No Don’t Know
XII. 24.
In the past TWO (2) WEEKS, has he/she talked about wanting to kill himself/herself or about wanting to commit suicide?
Yes No Don’t Know
25. Has he/she EVER tried to kill himself/herself? Yes No Don’t Know
p 3
Copyright © 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 11–17
Name: ________________________________ Date:___________
Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.
During the past TWO (2) WEEKS, how much (or how often) have you…
None Not at all
Slight Rare, less than a day
or two
Mild Several
days
Moderate More than
half the days
Severe Nearly every day
Highest Domain
Score
(clinician)
I. 1. Been bothered by stomachaches, headaches, or other aches and pains? 0 1 2 3 4
2. Worried about your health or about getting sick? 0 1 2 3 4
II. 3.
Been bothered by not being able to fall asleep or stay asleep, or by waking up too early?
0 1 2 3 4
III. 4.
Been bothered by not being able to pay attention when you were in class or doing homework or reading a book or playing a game?
0 1 2 3 4
IV. 5. Had less fun doing things than you used to? 0 1 2 3 4
6. Felt sad or depressed for several hours? 0 1 2 3 4
V. &
VI.
7. Felt more irritated or easily annoyed than usual? 0 1 2 3 4
8. Felt angry or lost your temper? 0 1 2 3 4
VII. 9. Started lots more projects than usual or done more risky things than usual? 0 1 2 3 4
10. Slept less than usual but still had a lot of energy? 0 1 2 3 4
VIII. 11. Felt nervous, anxious, or scared? 0 1 2 3 4
12. Not been able to stop worrying? 0 1 2 3 4
13. Not been able to do things you wanted to or should have done, because they made you feel nervous?
0 1 2 3 4
IX. 14.
Heard voices—when there was no one there—speaking about you or telling you what to do or saying bad things to you?
0 1 2 3 4
15. Had visions when you were completely awake—that is, seen something or someone that no one else could see?
0 1 2 3 4
X. 16.
Had thoughts that kept coming into your mind that you would do something bad or that something bad would happen to you or to someone else?
0 1 2 3 4
17. Felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off?
0 1 2 3 4
18. Worried a lot about things you touched being dirty or having germs or being poisoned?
0 1 2 3 4
19. Felt you had to do things in a certain way, like counting or saying special things, to keep something bad from happening?
0 1 2 3 4
In the past TWO (2) WEEKS, have you…
XI. 20. Had an alcoholic beverage (beer, wine, liquor, etc.)? Yes No
21. Smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco? Yes No
22. Used drugs like marijuana, cocaine or crack, club drugs (like Ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)?
Yes No
23.
Used any medicine without a doctor’s prescription to get high or change the way you feel (e.g., painkillers [like Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers [like sleeping pills or Valium], or steroids)?
Yes No
XII. 24.
In the last 2 weeks, have you thought about killing yourself or committing suicide?
Yes No
25. Have you EVER tried to kill yourself? Yes No
p 4
Client Name _______________________________________________ Revised 3.23.2016/reviewed 8.2016
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If yes, is teen receiving prenatal care?__________________
pg 5
Does child/teen have any current health needs not noted thus far? Y N If Yes, please describe:□ □
Does child/teen use any complementary health approaches? Y N If Yes, please describe:
please use back of page if needed
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Client Name _______________________________________________ Revised 3.23.2016/reviewed 8.2016
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Client Name _______________________________________________ Revised 3.23.2016/reviewed 8.2016
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Client Name____________________________________________________________________ Revised 3.23.2016/reviewed 8.2016
SUBSTANCE USE: Please complete chart below. Circle substances used by teen in last 48 hours. P.8
Please complete these questions for substances you currently use Category of Substance
Current use?
Ever used?
Prescribed? Amount & Frequency of use (e.g., 8 beers/day)
How often do you have a strong urge to use (hourly, daily, etc)
Use has led to problems (social, work, health, legal)
Don’t do what’s expected of me due to use
Others express concern about my use
Have tried to cut down or stop
Withdrawal symptoms
Caffeine (coffee, soda, energy drinks, etc)
☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y
Tobacco ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y Alcohol ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y Marijuana (pot, K2, salvia, etc)
☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y Hallucinogen (ecstasy, PCP, mushrooms , mescaline, DOM, ketamine/Special K, DMT, LSD, Robitussin, spices, etc)
☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y
Inhalant (glues, fuels, paints, computer dusting spray, etc)
☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y
Opioid (codeine, morphine, heroin, pain pills, oxycodone, vicodin, etc)
☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y
Anti-‐anxiety & sleeping medication (benzodiazepines such as Valium, Xanax, Klonopin, sleeping pills, such as Ambien, Sonata, etc)
☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y
Stimulant (meth, cocaine, ritalin, etc)
☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y Other (Describe): ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y ☐N ☐Y
Does teen travel with driver(s) under the influence? ☐N ☐Y Does teen drive after substance use? ☐N ☐Y Does teen see negative consequences to substance use? ☐N ☐Y What does teen like about substance use?
LEGAL INFORMATION Child/teen (currently and/or in the past): If any legal difficulties, describe: ☐Had difficulty with police ☐Appeared in juvenile conference ☐Been convicted of a crime ☐Been on probation ☐No history of legal problems LEISURE ACTIVITIES Please list child/teen’s non-‐school activities and preferences for spending non-‐school time:
Comments (e.g., enjoyment, satisfaction, etc):
Client Name____________________________________________________________________ Revised 3.23.2016/reviewed 8.2016
******************THIS IS THE END OF THE CLIENT PORTION OF THIS FORM********************pg9 For Therapist Use Only Observation of Client
SUBSTANCE USE ☐Family history of diagnosed or suspected substance use disorder ☐Personal history of use Possible Markers ☐Anxiety ☐Depression ☐Moody, angry, irritable ☐isolating self ☐sleep problems
☐parents do not like friends ☐conflict with family ☐focus/concentration problems Client substance use ☐larger amounts/longer period than intended ☐craving ☐failure to fulfill role obligations ☐desire to cut down/unsuccessful control attempts ☐excessive time obtaining/using/recovering ☐social/interpersonal problems ☐ use in hazardous situations ☐social/work/recreational activities reduced/given up ☐Use despite physical/psychological consequences ☐Withdrawal (characteristic w/d syndrome or use to relieve sx) ☐Tolerance (increased amounts to achieve effect of diminished effect with same amounts)
☐ Mild (2-‐3 sx above) ☐Moderate (4-‐5 sx above) ☐Severe (6+ sx above) ☐Remission (early, sustained) ☐on maintenance tx ☐in controlled environment ☐No meaningful SA concerns ☐Consult with site manager ☐Further screening/eval needed ☐Referral indicated Comments (if consult/eval needed, document date completed and consultant’s name below and detail relevant information in a progress note)
MEDICAL AND DEVELOPMENTAL HISTORY Motor development/functioning within normal limits? ☐ Y ☐N, describe
Speech, language, hearing, communication skills within normal limits? ☐ Y ☐N, describe
Visual functioning within normal limits? ☐ Y ☐N, describe
Congenital problems within normal limits? ☐ Y ☐N, describe
ADDITIONAL MEDICAL HISTORY (include adjustment (psychological, social, etc) to disabilities and/or medical conditions or ☐N/A as well as relationship of physical health to current mental health or ☐N/A as well as any current health needs or ☐N/A
PHYSICAL ACTIVITY & NUTRITION ☐no concerns ☐limited physical activity ☐calorie restriction ☐diet ☐food group avoidance ☐emotional overeating ☐binge eating ☐purging ☐ruminative thoughts about food/weight ☐body image concerns ☐history of food concerns ☐_____________________________________________________________________________ Assessment ☐incorporate physical activity into treatment ☐eating inventory assigned ☐consult with site manager ☐referral to specialist needed ☐no problem indicated
LEGAL STATUS (☐no legal concerns or history)
☐Client/parent/guardian given information about legal assistance if relevant
Client Name _______________________________________________ Revised 3.23.2016/reviewed 8.2016
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p10
Client Name _______________________________________________ Revised 3.23.2016/reviewed 8.2016
INITIAL RISK ASSESSMENT
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DIAGNOSTIC SUMMARY (including symptoms and functional impairment supporting DSM-5 diagnosis; include discussion if applicable of co-occurring disabilities, disorders, medical conditions, etc)
p11
Child/teen reports personal safety concerns No Yes, comments
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Client Name _______________________________________________ Revised 3.23.2016//reviewed 8.2016
DSM-5 Diagnosis (Code(s) and Description)
Ann Arbor Consultation Services
NOTICE OF PRIVACY PRACTICES Effective July 1, 2003
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: • “PHI” refers to information in your health record that could identify you.• “Treatment, Payment, and Health Care Operations”
– Treatment is when we provide, coordinate, or manage your health care and otherservices related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist. – Payment is when we obtain reimbursement for your healthcare. Examples of paymentare when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. – Health Care Operations are activities that relate to the performance and operation ofour practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and/or care coordination.
• “Use” applies only to activities within our clinic group, such as sharing, employing,applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of our clinic, such as releasing, transferring, orproviding access to information about you to other parties.
AACS may use or disclose PHI for purposes outside of treatment, payment, or health care operations when appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information.
You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage; or (3) if the law provides the insurer the right to contest the claim under the policy.
(Please see page 4 of this document for confidentiality specific to alcohol and drug abuse patient information)
In general, it is our preference to seek your permission prior to releasing information about you. However, we may use or disclose PHI without your consent or authorization in the following circumstances:
Revised 08.10.200/reviewed 8.2016
• Child and Elder Abuse – If we have reasonable cause to suspect child abuse, elder care orneglect, we must report this suspicion to the appropriate authorities as required by law.
• Health Oversight Activities – If we receive a subpoena or other lawful request from theDepartment of Health or other state or federal agencies, we must disclose the relevant PHIpursuant to that subpoena or lawful request.
• Judicial and Administrative Proceedings – If you are involved in a court proceeding and arequest is made for information about your diagnosis and treatment or the records thereof,such information is privileged under state law, and we will not release information withoutyour written authorization or a court order. The privilege does not apply when a third partyis evaluating you or where the evaluation is court ordered. You will be informed in advanceif this is the case.
• Serious Threat to Health or Safety – If you communicate to use a threat of physical violenceagainst a reasonably identifiable third person and you have the apparent intent and ability tocarry out that threat in the foreseeable future, we may disclose relevant PHI and take thereasonable steps permitted by law to prevent the threatened harm from occurring. If webelieve that there is an imminent risk that you will inflict serious physical harm on yourself,we may disclose information in order to protect you. If there is a medical emergency, wewill disclose any information to emergency medical personnel deemed necessary to providemedical care for you.
• When Legally Required -- AACS will disclose your protected health information when weare required to do so by any Federal, State or local law.
Therapist’s Duties
Patient’s Rights: • Right to Request Restrictions – You have the right to request restrictions on certain uses and
disclosures of protected health information. However, AACS is not required to agree to therestriction you request.
• Right to Receive Confidential Communications by Alternative Means and at AlternativeLocations – You have the right to request and receive confidential communications of PHI byalternative means and at alternative locations. (For example, you may not want a familymember to know that you are seeing us. On your request, AACS will send your bills toanother address.)
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI inour mental health and billing records used to make decisions about you for as long as the PHIis maintained in the record. AACS may deny your access to PHI under certaincircumstances, but in some cases you may have this decision reviewed. On your request,AACS will discuss with you the details of the request and denial process.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHIis maintained in the record. AACS may deny your request. On your request, AACS willdiscuss with you the details of the amendment process.
Revised 08.10.200/reviewed 8.2016
• Right to an Accounting – You have the right to receive an accounting of disclosures of PHI. Onyour request, AACS will discuss with you the details of the accounting process. Accountingrequests may not be made for periods in excess of six years.
• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us uponrequest, even if you have agreed to receive the notice electronically.
Clinic’s Duties • AACS is required by law to maintain the privacy of PHI and to provide you with a notice of our
legal duties and privacy practices with respect to PHI.
• AACS reserves the right to change the privacy policies and practices described in this notice.Unless we notify you of such changes, however, AACS is required to abide by the terms currentlyin effect.
• If AACS revises these policies and procedures, we will inform you with a revised notice at yournext appointment.
Complaints
If you are concerned that AACS has violated your privacy rights, or you disagree with a decision AACS has made about access to your records, you may contact our Privacy Officer, Karen Bowersox Ph.D., at our office at (734) 996-9111 ext 0.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We can provide you with the appropriate address upon request.
Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on July 1, 2003
Ann Arbor Consultation Services 5331 Plymouth Rd. Ann Arbor, MI 48105
734-996-9111734-996-1950 (fax)
revised 3.2017reviewed 3.2104
CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE
The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser, unless:
(5) The patient consents in writing; OR
(6) The disclosure is allowed by a court order; OR
(7) The disclosure is made to medical personnel in a medical emergency or to qualifiedpersonnel for research, audit, or program evaluation; OR
(8) The person commits or threatens to commit a crime either at the program or againstany person who works for the program.
Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to the United States Attorney in the district where the violation occurs.
Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.
(See 42 U.S.C. δ 290dd-2 for federal law and 42 C.F.R. Part 2 for federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records.)
Revised 03.29.2017/reviewed 8.2016
WHAT YOU CAN DO CLIENT NOTICE OFCONFIDENTIALITY
Talk to your program rights advisor. Maybe The confidentiality of alcohol and drug abuse
together you can find a simple solution to patient records maintained by this program is
your complaint. protected by Federal law and regulations.
Generally, the program may not say to a person For additional information or appeal, write to:
If that doesn't work, you can fill out a formal outside the program that a patient attends the
complaint. Your rights advisor has complaint program, or disclose any information identifying a Recipient Rights Coordinator
forms. patient as an alcohol or drug abuser UNLESS: Michigan Department of Public Health
* The patient consents in writing OSAS-LED-PR
After you give your complaint to your rights * The disclosure is allowed by a court order; or 3500 North Logan
advisor, the complaint will be investigated. * The disclosure is made to medical personnel in PO BOX 30035
You will receive a written answer to your a medical emergency or to qualified personnel Lansing, Michigan 48909
complaint within 30 working days. for research, audit, or program evaluation
Violation of this Federal law and regulations by a
If you do not accept the written answer to program is a crime. Suspected violations may be
your complaint, you have 15 working days to reported to appropriate authorities in accordance "The Michigan Department of Public
file an appeal to the Regional Rights Consultant. with Federal regulations. Health will not discriminate against
Your rights advisor will provide you with an any individual or group on the basis
appeal form or you can send for one by writing Federal law and regulations do not protect any of race, color, religion, national origin
to the address on this brochure. information about a crime commited by a patient or ancestry, age, sex, (or marital
either at the program or against any person who status) or handicap."
Within 30 working days, the regional rights works for the program or about any threat to
consultant will give you a written answer to commit such a crime.
your appeal.
Federal law and regulations do not protect any
If you do not agree with the written answer to information about suspected child or elder abuse or
your appeal, you can file another appeal to neglect from being reported under State law to By authority of Public Act 368 of 1978,
the State Rights Coordinator. appropriate State or local authorities. Federal laws as amended
do not protect information related to a client's intent
to commit suicide or homicide. AACS clinicians are
mandated to protect life and have a duty to warn
others of imminent harm. AACS is not a crisis
Your Program Rights Advisor:
Karen Bowersox, PhD
(734) 996-9111 Ext 0 intervention center, however we do handle emerency OSAS-LED-RR-301 REVISED 3/29/2017reviewed 8.2016calls from active clients 24 hours a day and may
refer you to police or the ER in times of crisis.
YOUR RIGHTS YOU HAVE THE RIGHT TO YOURWe are dedicated to providing you with EXPECT THAT THE PROGRAM RESPONSIBILITIESquality services. We also believe that STAFF WILL NOT * You are responsible for the payment ofyou should know how to make a complaint * Abuse or neglect you your bill including any portion yourif you believe that any of your rights have * Exploit you financially or otherwise insurance company does not pay for anybeen violated. * Retaliate against you or humiliate you reason
* * You are responsible for knowing if your
YOU HAVE THE RIGHT TOGive out information about you without your
permission, unless legally required to do so insurance company will pay for part or all* Informed consent for services, including
service delivery and concurrent services* Require you to be part of any research if you of your bill
Refuse services or service team membersdon't want to * You are responsible for providing clear and
* accurate information about yourself
YOU HAVE THE RIGHT * You are responsible for following the rules
* Freedom from seclusion or restraint TO KNOW of our program* Suggest changes in our service * How much our services cost, and how much * You are responsible for being considerate* Expect us to look into your complaints you must pay of the rights of others who are recipients of* Help us make up your own treatment plan * When violation of our program rules could services and our staff
lead to your discharge
and be told what will happen if you do
* All about any drugs that are used in your* Talk with your own doctor or lawyer treatment* Access to information needed to make treatment * If you, or any information about you will be
decisions and enough time to make those decisions used in any research or experiments YOUR RIGHTS ADVISOR* Obtain a copy or a summary or your client * About self-help, support group, advocacy, and If you think your rights have been violated at
legal resources available to you our program, please talk to your rights advisor. This person is interested in
record within 30 to 60 days of your requestunless the program director recommendsotherwise, and to information release listening to your complaint(s) and helping you
* Review your records, unless we determine find a solution.such a review would be harmful to you.
* Please see the AACS Consumer Handbook Your rights advisor's name and phone numberor talk to your clinician or the Recipient's are posted in the office, so please contactRights Advisor for more information on how your rights advisor if you believe your rightsto review your records or obtain copies.
If you would like to know more about your rights, please read our Rights of Persons Served Policy in our Consumer Handbook (located in waiting room and on our website) or ask the program rights advisor for a more complete list of your rights. have been violated.
All civil rights guaranteed by state andfederal law
*
The information you need in sufficient time tomake decisions
*
