FREEDOM OF INFORMATION
|
|
- Gyles Griffith
- 5 years ago
- Views:
Transcription
1 COMMUNITY UNIT SCHOOL DISTRICT HARNISH DRIVE ALGONQUIN, IL PHONE: Fax: FREEDOM OF INFORMATION February 1, 2017 Ms. Paulina Loza Re: FOIA Request Received January 31, our Record #980 Subject: A copy of the administration instruction to staff Level of care assessment procedures Dear Ms. Loza: I am responding to your January 31, 2017 request(s) under the Freedom of Information Act (5 ILCS 140/1 et seq.), in which you asked for the above referenced information. Enclosed is a copy of D300 s Level of Care Referral Process. Per your request, I will this response to you. This responsive document will be posted online at the District s website by end of day on February 3, which is two business days from today. To access it, go to then click Our District > Freedom of Information Act > View the FOIA Archive. Please let me know if you have additional questions. Thank you. Everlean Dodson Everlean Dodson Archives Manager
2 Level of Care Referral Process Teacher or staff member becomes aware of potential problem or behavior (Self-Injurious, Suicidal Ideation, Homicidal Behavior, Serious Risk of Health, Safety, Welfare of Self or Others) Individual will contact Social Worker, Counselor, or Psychologist and Building Administrator Assess Student Risk No Immediate Threat Mild to No Risk Immediate Threat Moderate to High Risk Imminent Threat Life-Threatening Call Parent as team deems appropriate Contact parent or Emergency Contact Person Call 911 Can recommend Level of Care Assessment SASS Referral Level of Care referral and complete school referral form and obtain release of information Contact Parent or Emergency Contact to inform them of situation Complete school referral form and obtain release Building principal is notified Building principal is notified of information and must complete the and must complete the Person Determined to Pose Person Determined to Pose a Clear and Present danger a Clear and Present danger Form within 24 hours of the Form within 24 hours of the referral and turn into the referral and turn into the District Safety Officer District Safety Officer Communicate outcomes with team and individual who Repeated made initial referrals referral to social worker, counselor, or psychologist should seriously be considered for a Level of Care Assessment. Remember to consider Child Find responsibilities.
3 Level of Care Assessment What is it? It is a formal referral to a mental health professional to determine if a student is a danger to himself or others. The team approach is the best way to handle it. 1) Principal, Assistant Principal, Psychologist, Social Worker, Nurse, Guidance Counselor, Teacher and Education Specialist as appropriate. 2) Anyone who has pertinent information to the situation that can assist. 3) Once the Level of Care Recommendation has been given, the staff member must communicate to the Principal or a building administrator by the end of the current school day. When do I refer a student? When a teacher or staff member becomes aware of a potential problem or behavior that may include: When a student is a danger to others in a building i.e. bringing a knife to school, threatening drawings, writings or statements, acts of violent physical aggression. Or When a student is harmful to self i.e. This may include threatening suicide, self-injurious behavior such as burning, cutting etc., highly agitated, at risk behaviors, severely depressed. Who do I refer to? Psychologist, Social Worker, or Guidance Counselor and Principal Who contacts the parent? Team decision- Most likely the administration for discipline related matters, or for social/emotional matters, the social worker, guidance counselor or psychologist. Stress that ONLY the assessment is free by some providers and that any type of treatment, therapy or services are the parents responsibility.
4 Level of Care Assessment Where can we refer the student for a level of care assessment? Alexian Brothers Behavioral Health Hospital- Hoffman Estates free Aunt Martha s Carpentersville Community Health Center Centegra health System Woodstock Kane County Community Crisis Center free Linden Oaks Behavioral Health McHenry County Crisis comes to building free Presence Saint Joseph Hospital - Elgin SASS- Cares Services (All kids or uninsured) Streamwood Behavioral Health Center- free Other facilitates as information becomes available. Family s Psychiatrist or Family Mental Health Provider- at parent s expense Proper forms must be filled out. (attach) o Have parent sign District Release of Information o Complete appropriate School Referral Form o Referral forms and evaluation results are to be kept in the nurse s file o The building principal must complete the Person Determined to Pose a Clear and Present Danger Form and give it to the District Safety Officer within 24 hours of the assessment being recommended. The person who contacts the parent (psychologist, social worker, or principal) will update the team on the outcome. Revised: March 2016
5 Screening Assessment and Support Services SASS What is SASS? SASS is a multi-department (DMH, HFS, DCFS) crisis intervention program for children and adolescents, who are experiencing a psychiatric emergency, which may result in a psychiatric hospitalization or intensive community based services. What is the Referral Process? Crisis and Referral Entry Service (CARES): The single point of entry to the Screening Assessment and Support Services Program that handles calls for children and youth in Illinois. CARES is a 24 hours a day, seven days a week hotline ,TTY CARES should be called when a child is a risk to himself or others and at any time you or others think a child is having a mental health crisis. CARES purpose is to ask questions of the child s parents, caregivers, or other callers about the child s behavior. CARES will then either send the local area SASS agency to see the child and guardian, or refer the child the guardian to community mental health or other services. Who Can Receive SASS Services? Any child or youth in a mental health crisis who qualifies or may qualify for public funding. Ex: Medicaid, DCFS wards or Illinois All Kids If the Child is Eligible for SASS services: SASS will work with the guardian and child for at least 90 days. If the child is hospitalized SASS will join the hospital team to care for the child. SASS will help the hospital team plan for the child s return home and will provide services when the child is home. If the child is not hospitalized, SASS will provide mental health services and supports to help the child stay at home. How Will Families Be Involved in Their Child s Care? To assure that services in the State of Illinois are both family-driven and youth-guided, families are the primary decision makers for their child s treatment. SASS will work closely with families to learn about the child s strengths and needs. Families/parents/guardians collaborate in the child s treatment.
6 SASS will provide and/or link the child and family to services, resources and supports to address the immediate crisis and begin to assist with building resilience. Parents will be offered the services of a Family Resource Developer (FRD). A FRD is a parent or guardian who has previously navigated the mental health system successfully for a child who has been diagnosed with a Serious Emotional Disturbance (SED).
7 Level of Care Referral Agency Contacts Information Alexian Brothers Behavioral Health Hospital 1650 Moon Lake Boulevard Hoffman Estates, IL Phone: Phone: For intake information or to speak with a counselor anytime, one call is all it takes. Available 24 hours a day, 7 days a week Aunt Martha s Carpentersville Community Health Center 3003 Wakefield Drive Carpentersville, Illinois Phone: Call or visit for comprehensive diagnostic evaluation and assessment. Centegra Health System 527 W. South Street Woodstock, IL Phone: (800) Centegra Behavioral Health Services is located at Centegra Specialty Hospital-Woodstock. For urgent assessments, to schedule an appointment with a qualified mental health professional, or to schedule a FREE chemical dependency screening, call (800) Kane County Community Crisis Center Available 24 Hours a Day
8 Crisis Line Business Line En Espanol Domestic Violence- Sexual Assault- Economic Crisis- Shelter Linden Oaks Behavioral Health 852 South West Street Naperville, IL Phone: McHenry County Crisis Provides assessments like SASS but for privately insured individuals Presence Saint Joseph Hospital, Elgin 77 North Airlite Street Elgin, IL Phone: Behavioral Health Intake/Referral Line - A 24 hour intake and information line for mental health services both through the hospital and in the community for adults and adolescents call In crisis situations, if unable to speak directly to a clinician, call SASS Screening, Assessment and Support Services (SASS) program for children and adolescents experiencing a mental health crisis. If you are in need of SASS Services or experiencing a mental health crisis, please contact the CARES line at If CARES determines that a client meets criteria, a crisis worker will be sent out to your location to perform an assessment on the client in crisis to determine the level of care needed. Streamwood Behavioral Healthcare System 1400 East Irving Park Road Streamwood, IL Phone:
9 Clinical assessment and referral staff are available 24 hours a day, 7 days a week. Call (630) or (800) and ask for the Assessment and Referral Department. The Department of Health and Human Services provides a free 5-step Risk Assessment resource to the mental health community. Information available at the following:
10 RISK OR THREAT ASSESSMENT GUIDE Warning Signs: A sign or indicator that causes concern for safety A. Imminent Warning Sign: A sign which indicates that an individual is very close to behaving in a way that is potentially dangerous to self or others. Imminent Warning Signs call for immediate action by school authorities and law enforcement. Imminent Warning Signs can include the following: Possession and/or use of firearm or other weapon Suicide threats or statements Detailed threats of lethal violence (time, place, method) Severe rage for seemingly minor reasons Severe destruction of property Serious physical fighting with peers, family, others. B. Early Warning Signs: Certain behavioral and emotional signs that when viewed in a context, may signal a troubled individual. Early Warning Signs call for a parent notification and possible Level of Care Referral. Early Warning Signs can include the following: Social withdrawal or lacking interpersonal skills Excessive feelings of isolation and being alone Excessive feelings of rejection Being a victim of violence, teasing or bullying Feelings of being picked on Expressions of violence in writings and drawings Uncontrolled anger History of discipline problems Drug and alcohol use Affiliation with gangs Talking about weapons or bombs General statements of distorted, bizarre thoughts Depression Marked change in appearance
11 Level of Care - Risk For Harm Categories 1. Imminent Risk for Harm: An individual is, or is very close to, behaving in a way that is potentially dangerous to self or others. Examples include: detailed threats of lethal violence, suicide threats, possession and/or use of firearms or other weapons, serious physical fighting, etc. Most of these individuals will need immediate hospitalization or arrest. 2. Moderate High Risk for Harm: An individual has displayed significant Early Warning Signs, has significant existing Risk Factors and/or Precipitating Events. There may be evidence of emotional distress (depression, social withdrawal, etc.) or of intentional infliction on others (bullying, intimidation, seeking to cause fear, etc). Most of these individuals will need to be referred for a Level of Care Assessment. 3. Mild-Low Risk for Harm: An individual has displayed Early Warning Signs, reveals little history of serious Risk Factors or dangerous behavior. There may be evidence of the unintentional infliction of distress on others (insensitive remarks, teasing taken too far). There may be evidence of poor decision making, false accusations. Most of these individuals will need to have their parent/guardian contacted and possibly recommend a Level of Care Assessment.
12 School Referral Form Date: Referring Person/Title: Student Name: DOB: School: Home Address: Phone: Parent/Guardian: Emergency Assessment or Scheduled Appointment (Please Circle) Release Signed: Yes or No (Please Circle) If no, Verbal permission: Yes or No (Please Circle) Reason for Referral: Significant statements, information or background which may assist in the assessment: Do you wish information on the disposition? (If release are signed by parent/guardian and/or student?) Yes or No If Yes: Via Phone In Writing or Both (Please circle) Doctor Use Only Assessment Completed By: Date: Feedback to Referral By: Date: Revised: March 2016
13 Community Unit School District Harnish Drive Algonquin, IL P F Authorization for Use and Disclosure of Protected Health Information and Education Records Patient/Student Name: Date of Birth: I hereby authorize: To disclose protected health information and/or educational records to (include first and last name): For the purpose of: The receiving/sending agency or person shall agree to comply with the provisions of the Family Educational Rights and Privacy Act as it relates to the indicated records. I have been advised as to my rights to inspect copy and challenge the contents of the records that are to be released and to limit consent to designated records or designated portions of information within the records. I further realize that I can revoke authorization for release at any time. This release is valid for one year from date signed. Pertinent information within the initialed areas is sought: Students Temporary Records Outside Agency Records Psycho-educational Records Special Education Files Anecdotal Records Disciplinary Record Social History Other Intake/Discharge Summaries Medical Records Diagnostic Information Developmental Records Psychological/Psychiatric Other Parent/Guardian Signature Date Witness Signature (Required to release Mental Health Records) Date Student Signature (Required if student is 12 years or older) Date 03/2016 Revised
14 Community Unit School District Harnish Drive Algonquin, IL P F Autorización para el Uso y Divulgación de Información de Salud y Expedientes Educativos Protegidos Nombre del Paciente/Estudiante: Fecha de Nacimiento: Por la Presente Autorizo a: Para revelar información médica confidencial y / o expedientes educativos a (incluir nombre y apellido): Para el propósito de: La agencia o persona recibiendo/enviando deberá aceptar cumplir con la disposiciones de los Derechos Educativos de la Familia y Ley de Privacidad tal como refiere expedientes indicados. Se me ha informado de mis derechos a inspeccionar la copia y cuestionar el contenido de los documentos que se darán a conocer y limitar mi aprobación a los archivos designados o ciertas partes de información dentro de los expedientes. También se que puedo revocar la autorización de divulgación de información en cualquier momento. Este documento es válido por un año a partir de la fecha que se firmo. Pertinent information within the initialed areas is sought: Expedientes Temporales Estudiantiles Expedientes de Agencia Exteriores Expediente Psico-Educativos Archivos de Educación Especial Expediente Anecdótico Expediente Disciplinario Historial Social Otro Firma del Padre/Tutor Resumen de Admisión / Alta Expediente Medico Información de Diagnósticos Expedientes de Desarrollo Psicológica / Psiquiátrica Otro Fecha Firma del Testigo (Necesaria para divulgar expediente de salud mental) Firma del Estudiante (Necesaria si el estudiante tiene más de 12 años) Fecha Fecha
Santa Barbara County Public Health Department MEDIA GUIDE
Santa Barbara County Public Health Department MEDIA GUIDE INTRODUCTION This guide is intended to assist the media in obtaining timely information from the Santa Barbara County Public Health Department
More informationBOARD OF EDUCATION POLICY MANUAL TABLE OF CONTENTS SECTION 3 - GENERAL SCHOOL ADMINISTRATION. 3:30 Line and Staff Relations/Succession of Authority
BOARD OF EDUCATION POLICY MANUAL TABLE OF CONTENTS SECTION 3 - GENERAL SCHOOL ADMINISTRATION 3:10 Goals and Objectives 3:20 OPEN 3:30 Line and Staff Relations/Succession of Authority 3:40 Superintendent
More informationJulie Berger, MS, NCC, LPC HOLY FAMILY COUNSELING CENTER Peachtree Industrial Blvd. Suite 120, Duluth, GA INTAKE FORM
INTAKE FORM We welcome you to our faith-based practice. It is our goal to help you through the difficulties you are experiencing by addressing the whole person and family with dignity. Our goal as your
More informationREFUSAL OF CARE AND/OR TRANSPORTATION
Operations 21 Page 1 REFUSAL OF CARE AND/OR TRANSPORTATION APPROVED: 1 Purpose: 1.1 To determine when a person is identified as a patient in the EMS system. 1.2 To establish a standard process for the
More informationMARENGO HIGH SCHOOL DISTRICT POLICY MANUAL TABLE OF CONTENTS GENERAL SCHOOL ADMINISTRATION
MARENGO HIGH SCHOOL DISTRICT POLICY MANUAL TABLE OF CONTENTS GENERAL SCHOOL ADMINISTRATION 3:10 Goals and Objectives 3:20 OPEN 3:30 Line and Staff Relations 3:30-APAdministrative Procedure Organizational
More informationNavigating Work Life Health. Affiliate Clinical Forms
Navigating Work Life Health Affiliate Clinical Forms Introduction Lytle EAP Partners is an independent consulting and service organization that provides development, implementation, and administration
More informationPolicy 3.19 Workplace Violence and Threat Assessment Team
Policy 3.19 Workplace Violence and Threat Assessment Team Purpose John Tyler is concerned about the safety, health and well-being of all of its students, faculty and staff. In adherence to Virginia Code
More informationChristopher Newport University
Christopher Newport University Policy: Campus Violence Prevention Policy Policy Number: 1055 Executive Oversight: President s Office, Chief of Staff Contact Office: Director of Human Resources Vice President
More informationOptima EAP Clinical Assessment Form
Optima EAP Clinical Assessment Form Complete the Clinical Assessment during first EAP session with an Optima Client. The completed Assessment is to be filed in the client s record. Client Name Session
More informationClarke County School District Research Proposal Submission Guidance
Clarke County School District Research Proposal Submission Guidance DISCLAIMER: Clarke County School District (CCSD) reserves the right to modify the research guidelines as needed. Therefore, CCSD reserves
More informationHIPAA Privacy Rule and Sharing Information Related to Mental Health
HIPAA Privacy Rule and Sharing Information Related to Mental Health Background The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provides consumers with important privacy rights
More informationDo You Qualify? Please Read Carefully:
Do You Qualify? Please Read Carefully: You are NOT eligible if any of these apply: I am pregnant I am under the age of 18 I have more than two children in my custody My child(ren) is(are) three years old
More informationNASSAU COUNTY SINGLE POINT OF ACCESS (SPOA) CHILDREN S INTENSIVE MENTAL HEALTH PROGRAMS
NASSAU COUNTY SINGLE POINT OF ACCESS (SPOA) CHILDREN S INTENSIVE MENTAL HEALTH PROGRAMS Date of Referral: Child s Name: Date of Birth: Gender: Social Security Number: Age: Address: Town: Zip: Phone: Legal
More informationDarling Downs and West Moreton PHN
Darling Downs and West Moreton PHN Access to Allied Psychological Services (ATAPS) Referral DARLING DOWNS GPs who have completed Mental Health Skills Training: 2715 (at least 20mins) 2717 (at least 40
More informationTHE COUNSELING PLACE ADULT INTAKE FORM Yearly Family Income:
Person to Contact in Case of Emergency Name Relationship Best Contact Number Alternative Contact Number Office Use Only Intake Date Reason for referral Counselor THE COUNSELING PLACE ADULT INTAKE FORM
More informationWestern New Mexico University Threat Assessment and Violence Prevention Plan
Western New Mexico University Threat Assessment and Violence Prevention Plan Table of Contents Mission Statement... 3 Purpose... 3 Who is Covered by this Plan... 4 Definitions... 5 Threat Assessment Team...
More informationINTAKE REGISTRATION FORM
INTAKE REGISTRATION FORM Therapist: of Appt: File Created Practice Fusion: Discovering new choices together File Created Kareo: Today s : PCP: CLIENT INFORMATION Last Name First M.I. D.O.B Marital Status
More informationDisclosure Statement
Disclosure Statement The state of Colorado requires that I, as a licensed psychotherapist, provide the following items of information to you as a client: Business Address and Phone: Mooney and Associates,
More informationFOSTER STUDENT SUCCESS
THE CARE TEAM OUR MISSION Create solutions for healthier communities by assisting in protecting the health, safety, and welfare of the students and members of the UNT Health Science Center community. FOSTER
More informationPerson to Contact in Case of Emergency. THE COUNSELING PLACE YOUTH INTAKE FORM Yearly Family Income:
Person to Contact in Case of Emergency Name Relationship Best Contact Number Alt. Number Office Use Only Intake Date Reason for referral Counselor Who Can Pick Up Client (if Minor) THE COUNSELING PLACE
More informationRIVER CITY ADVOCACY COUNSELING SERVICES 145 Landa Street New Braunfels, TX (830)
Date / / Client information: First name Middle initial Last name Parent/Legal Guardian (for 17 and under) Address Phone number Home Wk Cell Date of birth / / Sex Marital Status Ethnicity Employment status:
More informationReminders for you as you come in for your first appointment
Reminders for you as you come in for your first appointment * Please complete this paperwork and bring it to your first appointment If you are unable to complete this paperwork prior to your appointment,
More informationClient Information Form
Client Information Form Please read and complete all information requested. Date: Name: Address: City, State and Zip: Social Security Number: Home Phone: Work Phone: Cell Phone: E-mail: If client is a
More informationCampus Crime & Security Report Harrisburg Campus
Campus Crime & Security Report Harrisburg Campus Harrisburg University of Science & Technology strives to offer a safe and secure campus. The Director of Compliance has the primary responsibility for supervising
More informationCampus and Workplace Violence Prevention. Policy and Program
Campus and Workplace Violence Prevention Policy and Program SECTION I - Policy THE UNIVERSITY AT ALBANY is committed to providing a safe learning and work environment for the University s community. The
More informationCommunity Crisis Stabilization Treatment Response Protocols
Community Crisis Stabilization Treatment Response Protocols Crisis Response-Treatment Protocols [February, 2017] 1461 Kensington Ave Buffalo, New York 14215 716.898.4950 millenniumcc.org Table of Contents
More informationPsychological Services Agreement
John A. Watterson, Ph.D. 4101 Parkstone Heights Drive, Suite 260 Austin, Texas 78746 Phone: 512-306-0663 Fax: 512-306-8086 Website: www.johnwatterson.com Psychological Services Agreement Welcome to my
More informationWELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice.
WELCOME Those of us at Crossroads Counseling want to thank you for choosing to work with us and we want to make your time with us as productive as possible. In order to expedite the intake process, please
More informationImminent Risk Protocol and Procedure Key Terms and Definitions
Imminent Risk Protocol and Procedure Key Terms and Definitions Lethality Assessment Found in the forms section of REFER, this form is completed for all Suicide and/or Homicide calls. It is not intended
More informationParental Consent For Minors to Receive Services
Parental Consent For Minors to Receive Services Welcome to the University of San Diego s Wellness Area! We appreciate your coming our way, and look forward to working with you. The following provides important
More informationRULES OF DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES DIVISION OF MENTAL HEALTH SERVICES
RULES OF DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES DIVISION OF MENTAL HEALTH SERVICES CHAPTER 0940-3-9 USE OF ISOLATION, MECHANICAL RESTRAINT, AND PHYSICAL HOLDING RESTRAINT TABLE OF CONTENTS
More informationPRE-K Enrollment Form-Perryton ISD
PRE-K Enrollment Form-Perryton ISD Legal First Name: Middle Name: Legal Last Name: Social Security: Sex: DOB: Birthplace: Parent/Guardian Information 1. Relation Home Phone Cell Phone Physical Address
More information9.5 REFUSAL OF TREATMENT/TRANSPORT POLICY
9.5 REFUSAL OF TREATMENT/TRANSPORT POLICY PURPOSE This policy outlines the evaluation of a patient refusing treatment or transport and the documentation expected when obtaining such a refusal. POLICY I.
More information~ z;:;---- Suzanne Grimmesey, MFT
Pa g e 11 of 7 ALCOHOL, DRUG AND MENTAL HEAL TH SERVICES POLICY AND PROCEDURE Section Sub-section Clinical Practices and Services Effective: May 2006 Policy Policy# 8.300 Duty to Warn/Protect Against Threats
More informationLSU Health Sciences Center New Orleans Workplace Violence Prevention Plan
LSU Health Sciences Center New Orleans Workplace Violence Prevention Plan Effective January 1, 1998 Governor Mike J. Foster, Jr., of the State of Louisiana issued Executive Order MJF 97-15 effective March
More informationCOLONIAL SCHOOL DISTRICT
No. 819 COLONIAL SCHOOL DISTRICT SECTION: TITLE: OPERATIONS SUICIDE AWARENESS, PREVENTION AND RESPONSE ADOPTED: January 21, 2016 819 SUICIDE AWARENESS, PREVENTION AND RESPONSE 1. Purpose Act 71 of 2014
More informationHealing Path Counseling Center
Healing Path Counseling Center Main Office: 603 Old Liberty Rd. STE 1. Sykesville, MD 21117 Phone: 410-921-9004 Email: healingpathcounselingcenter.com Rachel Cochran LCSW-C CLIENT INTAKE FORM PERSONAL
More informationPolicy and Procedures for Program Evaluation
Chapter 6 Policy and Procedures for Program Evaluation Overview Evaluation of the Colorado Colorectal Screening Program will provide information about patient demographics and clinical outcomes necessary
More informationBasic Information. Date: Patient s Name: Address:
1 Basic Information : Patient s Name: Address: Home Phone: Work Phone: Cell Phone: Email: Age: Birth : Marital Status: Occupation: Educational History: Name, Address and Phone of Child s School Counselor
More information1/18/2012. SBIRT Protocol: for School Nurses and Other School Staff to Identify Students at Risk for Substance Use Related Problems.
SBIRT Protocol: for School Nurses and Other School Staff to Identify Students at Risk for Substance Use Related Problems. January 2012 INTRODUCTION The Screening, Brief Intervention, and Referral to Treatment
More informationTexas Mental Health Law
Texas Mental Health Law J. Ray Hays, Ph.D. Directions: To receive 4 hours continuing education credit for psychologists, licensed psychological associates, licensed professional counselors and licensed
More informationFAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013
FAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
More informationChilliwack Community Protocol For Dealing with High-Risk Student Behaviour. A Collaborative Response to Assessing Violence Potential
Chilliwack Community Protocol For Dealing with High-Risk Student Behaviour A Collaborative Response to Assessing Violence Potential Prepared by: Lower Mainland Safe Schools Committee, based on the Community
More informationPATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES
Helping People Perform Their Best PRIVACY, RIGHTS AND RESPONSIBILITIES NOTICE PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES Request Additional Information or to Report a Problem If you have questions
More informationCountyCare Critical Incident Reporting Form
A. *Tell us about you (the person or entity reporting the incident): Name: Organization: Email Address: Relationship to Member: Telephone Number: Other Contact Number: B. Tell us about the CountyCare member
More informationPresented by Chief Anne P. Glavin Chief of Police California State University, Northridge. PacWest SFS Conference San Diego May 13, 2015
Presented by Chief Anne P. Glavin Chief of Police California State University, Northridge PacWest SFS Conference San Diego May 13, 2015 From Columbine in April of 1999 To Recently Definition of Active
More informationNOTICE OF PRIVACY PRACTICES
535 East 70th Street New York, NY 10021 (212) 606-1000 Specialists in Mobility NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
More informationSPECIALIZED FOSTER CARE GUIDELINES MANUAL
DEPARTMENT OF MENTAL HEALTH CHILD WELFARE DIVISION SPECIALIZED FOSTER CARE GUIDELINES MANUAL SECTION 4: DMH PARTICIPATION IN THE DCFS CSAT PROCESS I. PURPOSE This release issues procedural guidelines for
More informationAvmed medicare. Keeping You Informed
Avmed medicare Keeping You Informed Summer/July 2016 inside Your Primary Care Physician... 2 Preventive Healthcare... 2 Transferring Your Medical Records... 3 Mental Health Benefits... 3 Medical Technology...
More informationWORKPLACE VIOLENCE PREVENTION. Health Care and Social Service Workers
WORKPLACE VIOLENCE PREVENTION Health Care and Social Service Workers DEFINITION Workplace violence is any physical assault, threatening behavior, or verbal abuse occurring in the work setting A workplace
More informationDepartment of Defense DIRECTIVE. SUBJECT: Mental Health Evaluations of Members of the Armed Forces
Department of Defense DIRECTIVE NUMBER 6490.1 October 1, 1997 Certified Current as of November 24, 2003 SUBJECT: Mental Health Evaluations of Members of the Armed Forces ASD(HA) References: (a) DoD Directive
More informationCOunselling & Career SERvices
Personal Counselling University of lethbridge COunselling & Career SERvices counselling.services@uleth.ca AH153 403-317-2845 Informed Consent for Personal Counselling Purpose: For you to understand the
More informationWelcome to LifeWorks NW.
Welcome to LifeWorks NW. Everyone needs help at times, and we are glad to be here to provide support for you. We would like your time with us to be the best possible. Asking for help with an addiction
More informationPediatric Psychology
Pediatric Psychology Welcome to Pediatric Psychology at CHOC Children's. Please read this information carefully and write down any questions that you might have, so that we can discuss them. PSYCHOLOGICAL
More informationNew Patient Information
New Patient Information PATIENT INFORMATION M / F Last Name First Name Middle Name Suffix- Jr, Sr, etc. Mr, Mrs, Ms, Dr Sex Date of Birth Social Security Number Alias- Nickname (Last, First, Middle) Permanent
More informationLou Eckart, Ph.D. and Associates Licensed Clinical Psychologists 22 Mill St. Suite 305 Arlington, MA
Lou Eckart, Ph.D. and Associates Licensed Clinical Psychologists 22 Mill St. Suite 305 Arlington, MA 02476 781-646-6306 Lou@Eckart-PhD.com PSYCHOLOGIST - PATIENT SERVICES AGREEMENT Welcome to our practice.
More informationMental Holds In Idaho
Mental Holds In Idaho Idaho Hospital Association Kim C. Stanger (4/17) This presentation is similar to any other legal education materials designed to provide general information on pertinent legal topics.
More informationViolence Prevention and Reporting of Incidents
1 ADMINISTRATIVE PROCEDURE 311 1. Purpose Violence Prevention and Reporting of Incidents 1.1 The director of education is dedicated to maintaining a safe, caring and respectful environment in all schools
More informationNIMRS Incident Reporting Changes Effective June 30 th 2013
NIMRS Incident ing Changes Effective June 30 th 2013 The Justice Center for the Protection of People with Special Needs (Justice Center) becomes operational on June 30, 2013, resulting in changes OMH Part
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. WHY ARE YOU GETTING
More informationDepartment of Defense MANUAL
Department of Defense MANUAL NUMBER 6400.01, Volume 1 March 3, 2015 Incorporating Change 1, April 5, 2017 USD(P&R) SUBJECT: Family Advocacy Program (FAP): FAP Standards References: See Enclosure 1 1. PURPOSE
More information907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services.
907 KAR 15:080. Coverage provisions and requirements regarding outpatient chemical dependency treatment center services. RELATES TO: KRS 205.520, 42 U.S.C. 1396a(a)(10)(B), 1396a(a)(23) STATUTORY AUTHORITY:
More informationX Name of Patient (Please Print) X Signature of Patient (or Parent/Legal Guardian) X Name of Parent/Legal Guardian (Please Print)
In Office Policies Identification - For the protection of our patients, and to reduce medical identity theft, all patients are required to present a valid insurance ID card and/or driver s license at the
More informationWelcome to Arboretum Pediatrics
Welcome to Arboretum Pediatrics Congratulations on your bundle of joy! We hope that you find this packet helpful in answering any questions you may have about our practice. If you have any questions or
More informationNOTICE OF PRIVACY PRACTICES
Amended September 2013 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
More informationMacomb County Community Mental Health Level of Care Training Manual
1 Macomb County Community Mental Health Level of Care Training Manual Introduction Services to Medicaid recipients are based on medical necessity for the service and not specific diagnoses. Services may
More informationRyan White Part A Quality Management
Quality Management Mental Health Services Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part A grant
More informationNOTICE OF PRIVACY PRACTICES
BUTTE COUNTY DEPARTMENT OF BEHAVIORAL HEALTH NOTICE OF PRIVACY PRACTICES Effective Date: 4/14/2003 THIS NOTICE DESCRIBES NOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
More informationDepartment of Defense INSTRUCTION
Department of Defense INSTRUCTION NUMBER 6400.07 November 25, 2013 Incorporating Change 1, April 3, 2017 SUBJECT: Standards for Victim Assistance Services in the Military Community References: See Enclosure
More informationPOLICY TITLE: Psychiatry Emergency: Involuntary Examination/Hospitalization Baker Act
Administrative Policy POLICY NO.: 200.02.101A POLICY TITLE: Psychiatry Emergency: Involuntary Submitted by: Daniel Castellanos, MD Title: Founding Chair, Department of Psychiatry & Behavioral Health Approved
More informationNathan Swisher, PsyD, PLLC
Nathan Swisher, PsyD, PLLC www.swishercounseling.com 970.381.6093 Client Intake Packet 1. Disclosure and Consent to Treatment (pages 2-4) - This form outlines my education, registration, your rights in
More informationMember Handbook. HealthChoices Allegheny County
Member Handbook HealthChoices Allegheny County Contents Welcome to Community Care! 3 About Community Care 6 Behavioral Health Services for HealthChoices Members 9 Getting Help 11 Your Rights and Responsibilities
More informationMobile Crisis Intervention
Mobile Crisis Intervention Providers contracted for this level of care or service will be expected to comply with all requirements of these service-specific performance specifications. Additionally, providers
More informationNOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES ( NOTICE ) DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Respect for
More informationPolicies, Procedures, Guidelines and Protocols
Title Policies, Procedures, Guidelines and Protocols Document Details Trust Ref No 2078-28878 Local Ref (optional) Main points the document covers Who is the document aimed at? Author Approved by (Committee/Director)
More information5. Name: Last First MI. Street Number and Name or P.O Box. City State ZIPCODE. City State ZIPCODE
508 - ILLINOIS CERTIFIED DOMESTIC VIOLENCE PROFESSIONAL CERTIFICATION EXAMINATION APPLICATION PLEASE PRINT IN INK 1. Exam Date Applying For: 2. Exam Location 3. Fee: $175.00 February Chicago Area Certified
More informationPATIENT INFORMATION RESPONSIBLE PARTY INFORMATION NAME: DOB: SEX: M / F SOCIAL SECURITY # RELATIONSHIP TO PATIENT: PHONE #: CELL#: EMPLOYER:
PATIENT INFORMATION NAME: DOB: SEX: MALE / FEMALE SOCIAL SECURITY #: MARITAL STATUS: ADDRESS: CITY: STATE: ZIP CODE: PHONE #: CELL#: E-MAIL: PATIENT'S EMPLOYER: OCCUPATION: WORK PHONE: WHERE IS THE BEST
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES Effective Date: July 12, 2017 THIS NOTICE OF PRIVACY PRACTICES ( NOTICE ) DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO
More informationLily M. Gutmann, Ph.D., CYT Licensed Psychologist 4405 East West Highway #512 Bethesda, MD (301)
Lily M. Gutmann, Ph.D., CYT Licensed Psychologist 4405 East West Highway #512 Bethesda, MD 20814 (301) 996-0165 www.littlefallscounseling.com PRACTICE POLICIES AND CONSENT TO TREATMENT WELCOME Welcome
More informationSchool-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax:
Dear Parents/Guardians: School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE 19807 Phone: 651-2100 Fax: 651-2111 The Wilmington Charter/Cab Calloway
More informationEducation, Training and Licensure
Meredith M. Sargent, Ph.D. Licensed Clinical Psychologist 2950 Northup Way, Suite 204 Bellevue, Washington 98004 425.739.4772 (phone) 425.739.4778 (fax) msargentphd@gmail.com Welcome to my practice! I
More informationPATIENT RIGHTS FORM. Patient Name:
Services provided by the Ruttenberg Autism Center are Outpatient Mental Health Services. It is the policy of the Ruttenberg Autism Center to afford individuals receiving Mental Health Services in Pennsylvania
More informationMinnesota Patients Bill of Rights
Minnesota Patients Bill of Rights Legislative Intent It is the intent of the Legislature and the purpose of this statement to promote the interests and wellbeing of the patients of health care facilities.
More informationHow did you hear about us? Patient s Last Name First Name Middle Initial. Patient s Social Security Number. Address Apt # City State Zip Code
Who is responsible for this patient? Self Parent Employer Other How did you hear about us? Patient s Last Name First Name Middle Initial Patient s Social Security Number of Birth Address Apt # City State
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Who Presents this
More informationPEDIATRIC HEALTH ASSOCIATES HIPAA NOTICE OF PRIVACY PRACTICES
Policy effective date: 4-14-2003 Revised January 2014 PEDIATRIC HEALTH ASSOCIATES HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
More informationINTAKE SURVEY FOR INITIAL INTERVIEW. Name Date Age Birth date Address: Phone numbers: Emergency Contacts & Relationship:
1 INTAKE SURVEY FOR INITIAL INTERVIEW Name Date Age Birth date Address: Phone numbers: Email: Emergency Contacts & Relationship: Phone numbers for EmergencyContacts: Employment or school grade Why are
More informationOSF HealthCare. Patient Rights and Responsibilities (Illinois)
OSF HealthCare Patient Rights and Responsibilities (Illinois) Our Mission In the spirit of Christ and the example of Francis of Assisi, the Mission of OSF HealthCare is to serve persons with the greatest
More informationCHILDREN S ADVOCACY CENTER, INC. CRAWFORD COUNTY PROTOCOL OF SERVICES
CHILDREN S ADVOCACY CENTER, INC. CRAWFORD COUNTY PROTOCOL OF SERVICES I. OVERVIEW A. INTRODUCTION This Protocol of Services for the Children s Advocacy Center, Inc. (CAC) was developed as a cooperative
More informationPsychologist-Patient Services Agreement
Psychologist-Patient Services Agreement Welcome! This document contains important information about my professional services and business policies. This document also contains a brief summary of information
More informationOSHA, Workplace Violence, and the Healthcare Facility Keeping Your Facility Safe and Compliant
OSHA, Workplace Violence, and the Healthcare Facility Keeping Your Facility Safe and Compliant Steve Wilder, BA, CHSP, STS Sorensen, Wilder & Associates 727 Larry Power Road Bourbonnais, IL 60914 800-568-2931
More information(PLEASE PRINT) Sex M F Age Birthdate Single Married Widowed Separated Divorced. Business Address Business Phone Cell Phone
(PLEASE PRINT) Emma Warner, MSW, LCSW, ACSW Tulsa, OK 74105 (918) 749-6935 Personal Information Name Address Last Name First Name Initial Home Phone Soc. Sec. # City State Zip Sex M F Age Birthdate Single
More informationMinnesota Patients Bill of Rights
Minnesota Patients Bill of Rights Legislative Intent It is the intent of the Legislature and the purpose of this statement to promote the interests and well-being of the patients of health care facilities.
More informationNOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES Effective Date: May 31, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
More informationWAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES
WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised February 17, 2010 Revised September 23, 2013 Revised July 1, 2016 This Notice of Privacy Practices applies to the
More informationINFORMED CONSENT FOR TREATMENT
INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care
More informationGENERAL POLICE ORDER CLEVELAND DIVISION OF POLICE
GENERAL POLICE ORDER CLEVELAND DIVISION OF POLICE ORIGINAL EFFECTIVE DATE : SUBJECT: ASSOCIATED MANUAL: REVISED DATE: 1/5/2017 NO. PAGES: 1 of 11 CRISIS INTERVENTION TEAM RESPONSE RELATED ORDERS: NUMBER:
More informationCadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE
Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE Date: / / Name: Date of Birth: / / Age: Sex: M F ETHNIC ORIGIN: White Hispanic Haitian African American Other: PRIMARY LANGUAGE: English Spanish
More informationMANDATED & RECOMMENDED TRAININGS FOR SCHOOL PERSONNEL
MANDATED & RECOMMENDED TRAININGS FOR SCHOOL PERSONNEL (This is an evolving document based upon current and/or pending legislation. Though presumed accurate, it may not be all-inclusive. Not all mandates
More informationGEORGIA DEPARTMENT OF JUVENILE JUSTICE I. POLICY:
GEORGIA DEPARTMENT OF JUVENILE JUSTICE Applicability: { } All DJJ Staff { } Administration { } Community Services {x} Secure Facilities (RYDCs and YDCs) Chapter 12: BEHAVIORAL HEALTH SERVICES Subject:
More information