Intake Form

 

  • Date Format: MM slash DD slash YYYY
    Please email front and back of insurance card admissions@compservhealth.com
    Please let us know how you found us.
  • Primary

  • English


    Proficiency:

    We do not currently have an spanish speaking staff members. Only English. We can refer you to someone else if you can not speak English.
  • Date Format: MM slash DD slash YYYY
  • Example Mon-Fri 9am-5pm
  • (Check all that apply): Law Enforcement

  • (Includes arrests, probation, parole, commitments, adjudications, diversions, or awaiting sentencing)

  • List: Prescribing Doctor: Medical Conditions that you are currently experiencing (please include HBP, Seizures, Diabetes, etc:
  • ADDICTION


    Type of Substance(s) Used

  • Date Format: MM slash DD slash YYYY
  • What are you being seen for?
  • Consumer Choice Form

    (consumer/guardian) I acknowledge that I have been given an opportunity to review a list of Endorsed Service Providers and the services they provide my area. I understand that only medically necessary services will be authorized.

  • Receipt and Acknowledgment of Notice

    I do hereby seek and consent to take part in treatment with Comp Serv Health Resources, Inc I have applied for, and consent to participate in, such Mental Health and Substance Abuse (MH/AD), crisis, evaluation and treatment services as are approved and recommended by the physician (or other appropriate staff) of Comp Serv Health . I understand that developing a treatment plan, regularly reviewing my progress toward meeting the treatment goals and regular participation in appointments are in my best interest. I agree to play an active role in this process.

    I understand that no promises have been made to me as to the results of treatment or of any procedures provided by Comp Serv Health.

    I am aware that I may stop my treatment with Comp Serv Health. at any time. The only thing I will still be responsible for is any outstanding financial responsibility. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court

    I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive.

    I acknowledge that I have been given the opportunity to have all my questions answered fully.

    I understand that if I have any questions regarding the Consent for Treatment Form; I can contact Comp Serv Health.

    My signature below shows that I understand and agree with all of these statements.

  • If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc

    I have discussed the issues above with the client (and/or his or her parent, guardian, or other representative My observations of this person’s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent.

  • ADDITIONAL CONSENTS

    CONSUMER RIGHTS & RESPONSIBILITIES

    I hereby acknowledge that I have received and have been given a copy of Comp Serv Health.’s Consumer Rights & Responsibilities. I understand that if I have any questions regarding the Consumer Rights & Responsibilities; I can contact Comp Serv Health. at (502)5613464.

    24/7 ONCALL SERVICE ACCESSIBILITY & CRISIS SERVICES

    Comp Serv Health. is dedicated to providing the very best care for our consumers. Our services are available 24 hours a day, 7 days a week, through oncall arrangements with our team members. A timely response will be available when a family requires face to face crisis intervention. Our team is always available to assist the consumer and his/her family in case of a crisis situation.

    crisis is defined as a situation where the child and/or family are in emotional conflict that cannot be resolved on his or her own. This would include for example but is not limited to an angry nonviolent child who the family is trying to calm down; a parent who is feeling overwhelmed and needs someone to help talk them through the problem.

    All consumers need to call 911 first when there is a threat of violence, suicidal/homicidal gestures,

    or aggression. COMPSERV HEALTH. can be contacted secondary for support.

    Crisis calls are accepted 24 hours a day, and 7 days a week. If a crisis occurs after normal business

    hours or Holidays, and Weekends and you cannot directly contact one of your COMPSERV HEALTH . Team Members, please call (502) 5613464.

    It is not our policy to treat illnesses, prescribe/administer medication or offer emergency medical attention over the phone. PLEASE CALL 911 for any medical and/or health care emergency.

    SECLUSION AND RESTRAINT POLICY

    It is the policy of Comp Serv Health. not to utilize any seclusion or restraint techniques with any consumer under any circumstances.

    I agree to allow CompServ Health . employees to implement professionally accepted methods of intervention and therapeutic strategies as indicated by the comprehensive person centered treatment plan that both the consumer/legally responsible representative and the service providers have developed.

    I, consent to Transportation by CompServ Health . staff and agree to hold CompServ Health . and its staff members harmless from any liability that results from the provision for transportation. I also consent to emergency medical treatment in the event that I am unable to provide such consent in an emergency.

  • GRIEVANCES/COMPLAINT POLICY

    I hereby acknowledge that I have received and have been given a copy of CompServ Health’s Grievances/Complaint Policy. I understand that if I have any questions regarding the Grievances/Complaint Policy form, I can contact CompServ Health. at (502) 561-3464.

    Domestic Violence Policy I hereby acknowledge that I have received information and have been given a copy of information on how to respond to domestic violence problems, dynamics of domestic violence and its effects on adults and children victims, legal remedies for protection, safety and risk issues, available community and victim resources and reporting requirements (rev 8/14/2017)

    CONSENT TO PARTICIPATE IN ACTIVITIES

    I authorize the above mentioned individual to in activities (i.e. swimming, field trips, bowling, etc inform CompServ Health . of any activities that the individual will not be able to participate in.

    FAMILY INVOLVEMENT CONSENT/DENIAL

    I consent to have the family members listed below involved in the planning and delivery of the services that I shall be receiving from CompServ Health for this period of service. I understand that, without this consent, the agency’s employees will not be allowed even to acknowledge to any family member that I am a consumer of their services.

  • I do not consent to have family members involved in the planning or delivery of the services I shall be receiving in this period of services

    Family members to be involved:
  • (If parent or legal guardian is indicated under “Relationship” then that individual may sign future forms as the representative of a child consumer)

    EMERGENCY CONTACT

    I have received a copy of the Emergency Contact Sheet that provides me with information on how to get assistance in case of an emergency during the day or after hours.

    MISSED APPOINTMENT

    The appointment times given to you are assigned to you alone. Please make every effort to make your schedule appointment. If you need to cancel an appointment please call the staff member working with you and/or the office as soon as possible.

    ADVANCE DIRECTIVES

    I have received a copy of the brochure/questionnaire on Advance Directive. I understand if I choose to participate, I will notify my primary care provider and submit a copy of my decision to be filed in my service record.

  • Purpose: The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, and to coordinate treatment services.

    If other purpose, please specify: Medical or Life Threatening Emergency

    Revocation: I understand that I have a right to revoke this authorization, verbally or in writing, at anytime by sending written notification to CompServ Health . I further understand that a revocation of the authorization is not effective to the extent that action has already been taken in reliance on the authorization.

  • Conditions

    I further understand that CompServ Health . will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:

    Authorization for Release of information

    If services are hindered, prevent clinician from properly advocating or acting in the client’s best interest, or create a danger due to clients refusal to sign authorization then CompServ Health may choose not to continue services to client.

    Form of Disclosure

    Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format, or electronically.

    Re-disclosure

    Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. Other types of information may be re-disclosed by the recipient of the information in the following circumstances:

    If you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, legal guardian

    HIPAA/ 45 CFR 160 and 164:

    Release of Information demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPPA), Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR 160 and 164, and all federal regulations and imperative guidelines promulgated there under. I understand that information received or medical records prepared after this release form is completed, regarding my condition and the service I have received in the course of my diagnosis and treatment, may be subject to release to authorized parties in compliance with federal and state law and the terms of this form. I understand that information to be released may include information regarding drug abuse, alcohol abuse, psychological/psychiatric/psychosexual impairments, HIV and/or AIDS or physical conditions. I understand that the Federal Privacy Rule (HIPAA) does not protect the privacy of information if re-disclosed and therefore request that all information obtained from this person or agency be held strictly confidential and not be further released by the recipient. I further understand that my eligibility for benefits, treatment or payment is not conditioned upon my provision of this authorization. I intend this document to be a valid authorization conforming to all requirements of the Privacy Rule. I understand that unless otherwise limited by state or federal regulations and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time. If not previously revoked, this consent will terminate one year from the date appearing below.

    I do hereby request that this authorization to disclose health information to be rescinded effective I understand that any action taken on this authorization prior to the rescinded date is legal and binding.

  • VERBAL REVOCATION

  • I do herby attest to the verbal request by authorization. The consumer and/or his legally responsible person has been advised that any action taken on the authorization prior to the rescinded date is legal and binding.
  • Please initial all that apply:
  • I understand that because I receive insurance, my minimum payment is $0.00

  • I agree to notify CompServ Health . when there is a change in my insurance coverage or county of residence immediately.

  • I understand that if there is a termination of my insurance for any reason, CompServ Health . will be unable to continue rendering services.

    AUTHORIZATION TO RELEASE MEDICAL INFORMATION:

    hereby authorize COMPSERV HEALTH . and attending physician to release medical information required in the processing of application for financial coverage for services rendered by the agency. Information from the treatment record may also be released to the insurance companies listed above and to any utilization review organizations associated with the above insurance company. This data may include discharge summaries, history and physical, lab work, progress notes and financial information relating to payment for services.

    the release of information shall be valid for a period of one year from the date shown below or until satisfaction of claims. I understand that this consent may be revoked by me in writing at any time except in the event that the information has already been released pursuant to this consent but before I have revoked my consent. By signing this document I fully accept the above terms as my responsibility.

  • Date Format: MM slash DD slash YYYY
  • ASSIGNMENT OF BENEFITS

    I hereby authorize payment directly to CompServ Health . of any insurance or government program benefits otherwise payable to me for services rendered. If my visit today is with a clinician that is Non Covered by my insurance company, I understand that I will be responsible for those charges. Any refunds due me shall be applied to any other outstanding balance for which I am responsible at CompServ Health.

  • Notice of Privacy Practices Receipt and Acknowledgment of Notice

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

    PLEASE REVIEW THIS NOTICE CAREFULLY.

    Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI” This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHIS that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

    HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

    For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

    For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

    For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization

    Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

  • Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

    Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department) Required by Court Order Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

    Verbal Permission

    We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

    With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

    YOUR RIGHTS REGARDING YOUR PHI

    You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at [101 North Seventh Street Louisville Ky ]:

    Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period. Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request. Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Right to a Copy of this Notice. You have the right to a copy of this notice.

    COMPLAINTS

    If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer or with the U.S. Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201or by calling (202) 619-0257. We will not retaliate against you for filing a

    ACKNOWLEDGEMENT

    I hereby acknowledge that I have received and have been given an opportunity to read a copy of CompServ Health . Notice of Privacy Practices.

  • Consumer Rights & Responsibilities Receipt and Acknowledgment of Notice

    Your rights as a consumer, including confidentiality of your participation in evaluation and treatment services, will be observed in accordance with O.C.G.A. 37-3-166, 37-4-125, 37-7-166, DHR Rules and Regulations for Consumer Rights, Chapter 290-0-9; 42 U.S.C. 290dd-2,and CompServ Health . Consumer Rights and Responsibilities Policy #2330, CompServ Health . program policies and any other applicable laws, regulations, and policies, including the federal Health Insurance Portability and Accountability Act (HIPAA) privacy regulations. A summary of these rules and regulations will be reviewed with you and are available for inspection at each service location. You also will be provided a copy of the CompServ Health . HIPAA Privacy Notice. This information will be reviewed on an annual basis with you.

    YOU HAVE THE RIGHT:

    1. To services without discrimination on account of race, religion, sex, ethnicity, age, sexual orientation, disability or cultural background. 2. To exercise all fundamental human, civil, constitutional, and statutory rights to which you are entitled as a legally competent citizen unless such rights are limited under due process of law. 3. To be treated in a manner that respects your individual dignity and protects your health and safety at all times. 4. To receive care that is suited to your needs in the least restrictive environment available that affords reasonable protection from harm, exploitation, and coercion. 5. To receive prompt and confidential services in a respectful and dignified manner even if you are unable to pay, subject to a review of your financial status. 6. To refuse services, after being informed of the potential risks and consequences of refusal, unless a physician or licensed psychologist determines that refusal would be unsafe for you or others, or a court mandates the service. 7. To receive care and treatment suited to your needs in a skillful, safe and humane manner with full respect for your dignity and personal integrity. 8. To a written individualized service plan. 9. To participate in planning individualized service plan and to be promptly and fully informed of any changes in the plan of treatment. 10. To participate, to the extent possible, in your own care and treatment, to be told your diagnosis and to participate in the development and implementation of plan of care. 11. To be informed of the benefits, side effects and risks of psychotropic medications in a manner and language that you can understand. 12. To be given the opportunity to secure legal counsel at your expense. 13. To receive considerate and respectful care and to be free from physical, verbal, sexual, chemical, and mental abuse, neglect, humiliation or mistreatment. Emergency interventions may only be applied when necessary to protect the consumers from injury to himself/herself or others according to the procedures outlined by the organization. 14. To be free from time-out procedures unless such procedures are used solely for the purpose of providing effective treatment to you and protecting your safety and that of others. 15. To be free from isolation, physical and chemical restraints unless such interventions are required to protect you or others from injury, or such restraints are otherwise determined to be required for your treatment. 16. To have and retain personal property which does not jeopardize the safety of the consumer or other consumers or staff and have such property treated with respect. 17. To converse privately, have convenient and reasonable access to telephone, mail, and to see visitors. 18. Parents/guardians of children or adolescents have the right to be involved on behalf of their children with limited exceptions. 19. To file a complaint without fear of restraint, interference, coercion, discrimination or retaliation. Any CompServ Health . (and its programs) staff person or the Consumer and Family Advocate can take your complaint and/or assist you in completing the Consumer & Family Grievance form. 20. All consumers have the right to expect that their records are confidential unless you have given permission to give out information or reporting is required or permitted by law. When the organization releases records to others, such as insurance, it emphasizes the records are confidential.

  • 21. To be fully informed of all services available to them. The charges for those services are available to consumers as well as the right to examine and review bills for treatment, regardless of payment source. 22. To receive a written notice of the address and telephone number of the state licensing authority in order to obtain responsibilities of licensing the program and investigating consumer complaints which appear to violate rules. 23. To obtain a copy of the program’s most recent completed report of licensing inspection from the program upon written request

    HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY PRIVACY PRACTICES

    24. To access or inspect your health care information unless a physician determines that the record review would be detrimental to your well being. 25. To obtain a copy of your health care information for as long as the information is retained. (A reasonable fee may be charged for copying 26. To request in writing that CompServ Health . and its programs restrict the use and disclosure of your confidential health care information. 27. To receive a copy of the notice of the CompServ Health . HIPAA privacy practices. 28. To make a reasonable request in writing to receive phone, written or e-mail communications from CompServ Health . and its programs by alternative means or locations. 29. To request a list of when and to whom your health care information was released without your authorization within 6 years of your request for non-routine disclosures made on or after April 14, 2003. 30. To request an amendment to your health care information.

    CONSUMERS’ RESPONSIBILITIES AS A CONSUMER OF COMPSERV HEALTH . AND ITS PROGRAMS, IT IS YOUR ESPONSIBILITY:
  • Initial Below
  • expressing any concerns about your ability to follow the proposed care plan and to ask questions when you do not understand.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • I have provided the above named consumer/legal guardian/representative with a copy of the summary of Rights and Responsibilities and have also offered them a copy of the CompServ Health . and its programs HIPAA Notice of Privacy Practices.

  • Limits of Confidentiality

    The contents of a counseling, intake, or assessment session are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. It is the policy of this organization not to release any information about a client without a signed release of information. Noted exceptions are as follows:

    Duty to Warn and Protect

    When a client discloses intentions or a plan to harm another person, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. In addition, it may be necessary for the health care professional to take steps for the client to be placed in a restricted hospital environment to ensure the safety of the client and of others.

    Abuse of Children and Vulnerable Adults

    If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse or neglect, the health care professional is required to report this information to the appropriate social service and/or legal authorities.

    Prenatal Exposure to Controlled Substances

    Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

    In the Event of a Client’s Death

    In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records.

    Professional Misconduct

    Other health care professionals must report professional misconduct by a health care professional. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.

    Court Orders

    Health care professionals are required to release records of clients when a court order has been placed. Clients who are on probation, court ordered to treatment or referred by the Department of Juvenile Justice, Department of Human Resources or the county Juvenile Court may have waived certain rights to confidentiality when entering the treatment program.

    Minors/Guardianship

    Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.

    Audio/Video Taping

    In the event it becomes necessary to audio and/or video tape a client for treatment or supervision purposes, a specific consent form for the purpose of audio and/or video will be required. No recordings of any kind will be conducted without the expressed consent of the client.

    Other Provisions

    CompServ Health. does not conduct research on any of their clients. Outcome measures, as it pertains to the effectiveness or non-effectiveness of the treatment services are collected and analyzed to ensure that the best quality treatment is provided. No personal information on any client is disclosed, nor can any client be identified by any of outcome information collected.

    Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.

  • Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed. In some cases notes and reports are dictated/typed within the clinic or by outside sources specializing (and held accountable) for such procedures. When couples, groups, or families are receiving services, separate files are kept for individuals for information disclosed that is of a confidential nature. The information includes (a) testing results, (b) information given to the mental health professional not in the presence of other person(s) utilizing services, (c) information received from other sources about the client, (d) diagnosis, (e) treatment plan, (f) individual reports/summaries, and (h) information that has been requested to be separate. The material disclosed in conjoint family or couples sessions, in which each party discloses such information in each other’s presence, is kept in each file in the form of case notes. In the event in which the company or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please list where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we do not say the name of the clinic or the nature of the call, but rather the mental health professional’s first name only.

    Please check where you may be reached by phone. Include phone numbers and how you would like us to identify ourselves when phoning you.

    Phone number: How should we identify ourselves?

  • How should we identify ourselves?

  • SAFETY PLAN AGREEMENT

    In the event in which the safety of a member of a family that we service is compromised a safety plan is the most effective means of addressing and ensuring that any crisis is rendered nonexistent or minimized. To ensure that you and your family are always safe, we request that you agree to the following terms:

    As a volunteer participant in services, I, possession of any weapons or feelings of suicide to the members of the respective clinical team that is working with me and my family. I also agree to not use any item that can inflict injury to me or any member of my family. If the situation arises when my frustration is to the point that I want to physically harm myself or someone else, I will contact a member of the clinical team to process the occurrence in a therapeutic and non-threatening manner.

    If the situation is violent in nature or defined as an emergency, I will immediately contact the local authorities by dialing 911 (If applicable I will also contact a family member or family friend, , at as an additional resource to assist. I, or members from the clinical team that is working with me and my family, may also contact my caseworker, probation officer, or the referral source to inform them of any violent/suicidal occurrences or threats/expressions of violence/suicidal occurrences. Upon informing the clinical team members of possible violent/suicidal thoughts, and it is deemed that I present to be a danger to myself or others, I understand that they have the ethical and clinical obligation to contact the proper authorities.

  • I understand that information regarding my referral for treatment for substance abuse is protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Records 42 CFR Part 2, and cannot be disclosed without any written consent unless otherwise provided for in the regulations. I also understand that expect for action already taken based on my consent, I may revoke this consent at any time. If I do not revoke this consent, it will automatically expire no more than one year from when it is signed or upon my termination from services, whichever comes first.

    I specifically consent for information related to my treatment to be released to my parent/guardian: (initials) (For minors under 18)

  • ORIENTATION CHECKLIST & CLIENT RIGHTS

    The client rights’ has been provided as part of the consumer orientation. A check of the item and the signatures below indicate that each area has been fully explained and is understood by the consumer. After 1 year of service each consumer will be re-issued client rights’ Information.

    Rights and grievance and appeal procedures Services provide, days and hours of operation, expected level of participation Access to emergency services, after hours Code of Ethics/Conduct Confidentiality policy, limits of confidentiality Methods, opportunities, and policy on input Explanation of financial obligations, fees, and financial arrangements Fire, safety, and emergency precautions Policy on restraint Policy on tobacco products Policy on illicit or licit drugs brought into the program Policy on weapons brought into the program Identification of the person responsible for service coordination Program rules, including restrictions and the loss and regaining of rights AIDS/HIV Prevention Information Hepatitis Prevention & Treatment Information Purpose and process of bio-psychosocial assessment Individual plan development Discharge/ transition criteria and procedures

    COMPSERV HEALTH . Staff Signature

    Consent for Disclosure of Substance Abuse Information

  • I hereby authorize the disclosure of the following

    information about my referral for treatment for substance abuse from my records:

    Name and other personal identifying information Initial evaluation and /or screening results Date of admission Assessment results Summary of treatment plan Attendance Date of discharge and discharge status Discharge Plan

    The purpose of these disclosures if to provide for further, in depth substance abuse assessment for consumer within COMPSERV HEALTH Services as well as the community at large and to coordinate and plan appropriate intervention and treatment services as indicated by assessment data.

  • I have read all the above information and I agree to all the information provided above and all consents
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