Intake Form

Presenting Problems

If suicidal, homicidal, gravely impaired, or dangerous behaviors or need further clinical guidance, contact a licensed clinician to further assess for triage! Document clinical disposition when applicable.

1. To be informed of the client's rights and responsibilities at the time of admission or within 24 hours of admission.

2. To have a family member, chosen representative, and/or his or her own physician notified of admission to the BHS provider at the request of the client.

3. To receive treatment and medical services without discrimination based on race, age, religion, national origin, gender, sexual orientation, or disability.

4. To maintain the personal dignity and respect of each client.

5. To be free from physical, chemical, mental abuse, neglect, exploitation, harassment, retaliation, and humiliation.

6. To receive care in a safe setting.

7. To receive the services of a translator or interpreter, if applicable, to facilitate communication between the clients and the staff.

8. To be informed of the client’s own health status and to participate in the development, implementation, and updating of the client’s treatment plan.

9. To make informed decisions regarding the client’s care by the client or the client’s parent or guardian, if applicable, in accordance with federal and state laws and regulations.

10. To participate or refuse to participate in experimental research when the client gives informed, written consent to such participation, or when a client’s parent or legal guardian provides such consent, when applicable, in accordance with federal and state laws and regulations.

11. To be informed, in writing, of the policies and procedures for filing a grievance and their review and resolution.

12. To submit complaints or grievances without fear of reprisal.

13. To have the client’s information and medical records, including all computerized medical information, kept confidential in accordance with federal and state statutes and rules/regulations.

14. To be given a copy of the program's rules and regulations upon admission.

15. To receive treatment in the least restrictive environment that meets the client’s needs.

16. To not be restrained or secluded in violation of federal and state laws, rules, and regulations.

17. To be informed in advance of all estimated charges and any limitations on the length of services at the time of admission or within 72 hours;

18. To receive an explanation of treatment or rights while in treatment.

19. To be informed of the:

a. Nature and purpose of any services rendered.

b. The title of the personnel providing that service.

c. The risks, benefits, and side effects of all proposed treatment and medications.

d. The probable health and mental health consequences of refusing treatment; and

e. Other available treatments which may be appropriate.

20. To accept or refuse all or part of the treatment, unless prohibited by court order or a physician deems the client to be a danger to self or others or gravely disabled.

CLIENT/MEMBER RESPONSIBILITIES:

Your part is to take responsibility for the following:

1. Follow agency rules, policies, and procedures.

2. Follow the steps described in this handbook if you wish to file a grievance or appeal with our agency.

3. Keep scheduled appointments and call to cancel or reschedule if you cannot make your scheduled appointment.

4. Ask questions when you don’t understand or when you want more information.

5. Provide any information to your worker that is necessary for your treatment.

6. Participate actively to create goals that will help you in your recovery.

7. Follow the treatment plans that you and your providers have agreed upon.

8. Take medications as they are prescribed for you.

9. Tell your doctor if you are having unpleasant side effects from your medications, or if your medications do not seem to be working to help you feel better.

10. Seek out additional support services in the community.

11. Invite the people (family, friends, etc.) who will be helpful and supportive to you to be included in your treatment.

12. Understand your rights and the grievance process.

13. Treat staff, as you would expect to be treated.

I, give my permission to receive counseling/therapy services from The Gift. I understand that by giving my permission to receive services, I have the right to withdraw my consent at any time. Withdrawal of my consent will result in my file being closed immediately. By giving my permission to receive services, I understand that I, as a client, have the right to confidentiality, the right to privileged communication, responsibilities I must uphold as a client, and the right to refuse service at any time. I understand that I, as a client, have the right to give informed consent to individuals, agencies, and/or organizations to view my file. I understand that I, as a client, have the right to request, in writing, information in my file at any time.

By signing below, I am agreeing that I have read and understand the above information and agree to the following services:

• Assessment Group Counseling
• Education Family Counseling
• Couples Counseling Psychiatric Evaluation
• Medication Management Other CPST & PSR