Authorization of Use or Disclosure of Protected Health Information

Transcription

1 Authorization of Use or Disclosure of Protected Health Information Client Name: Client ID: DOB: In order to provide an appropriate therapeutic program it is often necessary to exchange information with other programs, agencies and professionals. Before we can exchange information, we need your written authorization. Information received from other sources cannot be released by Friendship House. The information is to be disclosed by: And is to be provided to: Name of Person/Organization/Facility Name of Person/Organization/Facility Address Address City/State/Zip The purpose or need for this disclosure is: Further Medical Care Attorney School Research The information to be disclosed from my health record: School Information Academic Testing Education Transcripts Individual Education Plan Evaluation Report Re-Evaluation Report Disciplinary Reports Nursing Report Report Card Psychological Evaluation FBA Attendance Records PSSA City/State/Zip Personal Use Insurance Mental / Behavioral Health BioPsychoSocial History Individual Treatment Plan ITP Reports Treatment Plan Reviews Interagency Meeting Reports Discharge Summary Foster Care / Residential Home Study Individual Service Plan ISP Reports Discharge Summary Disability Other: Medical / Physical Health Client Health History Immunization Records Physical Examinations Laboratory Test Results Medication Records Medical Referrals Physician Orders Psychiatric / Psychological Psychiatric Evaluation Psychological Evaluation Psychiatric Addendum Medication Reviews Verbal Communication*must specify nature of communication Other: Only information related to (specify) Only the period of events from: / / to / / Other (specify) Entire Record If you would like any of the following sensitive information disclosed, check the applicable below: Alcohol/Drug Abuse Treatment/Referral Sexually Transmitted Diseases HIV/AIDS-related Treatment Psychotherapy Notes ONLY (by checking, I am waiving any psychotherapist-patient privilege) I understand that I may revoke this authorization in writing submitted at any time to the Friendship House, except to the extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated. Specify new date: / / Signature of Client / Parent / Guardian Relationship Date Time Witness * Witness Date * Witness 2nd Witness Required if responsible person is physically unable to sign but understands the nature of this release. This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Time

2 Authorization of Use or Disclosure of Protected Health Information Client Name: Client ID: DOB: In order to provide an appropriate therapeutic program it is often necessary to exchange information with other programs, agencies and professionals. Before we can exchange information, we need your written authorization. Information received from other sources cannot be released by Friendship House. The information is to be disclosed by: And is to be provided to: Name of Person/Organization/Facility Name of Person/Organization/Facility Address Address City/State/Zip The purpose or need for this disclosure is: Further Medical Care Attorney School Research The information to be disclosed from my health record: School Information Academic Testing Education Transcripts Individual Education Plan Evaluation Report Re-Evaluation Report Disciplinary Reports Nursing Report Report Card Psychological Evaluation FBA Attendance Records PSSA City/State/Zip Personal Use Insurance Mental / Behavioral Health BioPsychoSocial History Individual Treatment Plan ITP Reports Treatment Plan Reviews Interagency Meeting Reports Discharge Summary Foster Care / Residential Home Study Individual Service Plan ISP Reports Discharge Summary Disability Other: Medical / Physical Health Client Health History Immunization Records Physical Examinations Laboratory Test Results Medication Records Medical Referrals Physician Orders Psychiatric / Psychological Psychiatric Evaluation Psychological Evaluation Psychiatric Addendum Medication Reviews Verbal Communication*must specify nature of communication Other: Only information related to (specify) Only the period of events from: / / to / / Other (specify) Entire Record If you would like any of the following sensitive information disclosed, check the applicable below: Alcohol/Drug Abuse Treatment/Referral Sexually Transmitted Diseases HIV/AIDS-related Treatment Psychotherapy Notes ONLY (by checking, I am waiving any psychotherapist-patient privilege) I understand that I may revoke this authorization in writing submitted at any time to the Friendship House, except to the extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated. Specify new date: / / Signature of Client / Parent / Guardian Relationship Date Time Witness * Witness Date * Witness 2nd Witness Required if responsible person is physically unable to sign but understands the nature of this release. This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Time

3 Authorization of Use or Disclosure of Protected Health Information Client Name: Client ID: DOB: In order to provide an appropriate therapeutic program it is often necessary to exchange information with other programs, agencies and professionals. Before we can exchange information, we need your written authorization. Information received from other sources cannot be released by Friendship House. The information is to be disclosed by: And is to be provided to: Name of Person/Organization/Facility Name of Person/Organization/Facility Address Address City/State/Zip The purpose or need for this disclosure is: Further Medical Care Attorney School Research The information to be disclosed from my health record: School Information Academic Testing Education Transcripts Individual Education Plan Evaluation Report Re-Evaluation Report Disciplinary Reports Nursing Report Report Card Psychological Evaluation FBA Attendance Records PSSA City/State/Zip Personal Use Insurance Mental / Behavioral Health BioPsychoSocial History Individual Treatment Plan ITP Reports Treatment Plan Reviews Interagency Meeting Reports Discharge Summary Foster Care / Residential Home Study Individual Service Plan ISP Reports Discharge Summary Disability Other: Medical / Physical Health Client Health History Immunization Records Physical Examinations Laboratory Test Results Medication Records Medical Referrals Physician Orders Psychiatric / Psychological Psychiatric Evaluation Psychological Evaluation Psychiatric Addendum Medication Reviews Verbal Communication*must specify nature of communication Other: Only information related to (specify) Only the period of events from: / / to / / Other (specify) Entire Record If you would like any of the following sensitive information disclosed, check the applicable below: Alcohol/Drug Abuse Treatment/Referral Sexually Transmitted Diseases HIV/AIDS-related Treatment Psychotherapy Notes ONLY (by checking, I am waiving any psychotherapist-patient privilege) I understand that I may revoke this authorization in writing submitted at any time to the Friendship House, except to the extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated. Specify new date: / / Signature of Client / Parent / Guardian Relationship Date Time Witness * Witness Date * Witness 2nd Witness Required if responsible person is physically unable to sign but understands the nature of this release. This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Time

4 Authorization of Use or Disclosure of Protected Health Information Client Name: Client ID: DOB: In order to provide an appropriate therapeutic program it is often necessary to exchange information with other programs, agencies and professionals. Before we can exchange information, we need your written authorization. Information received from other sources cannot be released by Friendship House. The information is to be disclosed by: And is to be provided to: Name of Person/Organization/Facility Name of Person/Organization/Facility Address Address City/State/Zip The purpose or need for this disclosure is: Further Medical Care Attorney School Research The information to be disclosed from my health record: School Information Academic Testing Education Transcripts Individual Education Plan Evaluation Report Re-Evaluation Report Disciplinary Reports Nursing Report Report Card Psychological Evaluation FBA Attendance Records PSSA City/State/Zip Personal Use Insurance Mental / Behavioral Health BioPsychoSocial History Individual Treatment Plan ITP Reports Treatment Plan Reviews Interagency Meeting Reports Discharge Summary Foster Care / Residential Home Study Individual Service Plan ISP Reports Discharge Summary Disability Other: Medical / Physical Health Client Health History Immunization Records Physical Examinations Laboratory Test Results Medication Records Medical Referrals Physician Orders Psychiatric / Psychological Psychiatric Evaluation Psychological Evaluation Psychiatric Addendum Medication Reviews Verbal Communication*must specify nature of communication Other: Only information related to (specify) Only the period of events from: / / to / / Other (specify) Entire Record If you would like any of the following sensitive information disclosed, check the applicable below: Alcohol/Drug Abuse Treatment/Referral Sexually Transmitted Diseases HIV/AIDS-related Treatment Psychotherapy Notes ONLY (by checking, I am waiving any psychotherapist-patient privilege) I understand that I may revoke this authorization in writing submitted at any time to the Friendship House, except to the extent that action has been taken in reliance on this authorization. If this authorization was obtained as a condition of obtaining insurance coverage or a policy of insurance, other law may provide the insurer with the right to contest a claim under the policy. If this authorization has not been revoked, it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated. Specify new date: / / Signature of Client / Parent / Guardian Relationship Date Time Witness * Witness Date * Witness 2nd Witness Required if responsible person is physically unable to sign but understands the nature of this release. This information is to be released for the purpose stated above and may not be used by the recipient for any other purpose. Time

5 Autism Behavior Management Consent Client Name: Client ID: DOB: Behavior Management Interventions The Autism Program at Friendship House is committed to applying positive reinforcement and skill building to improve your child's communication, socialization and daily living skills. We believe that by teaching your child functional communication skills we avoid many behavioral difficulties, especially those caused by frustration surrounding unmet needs. We also believe that teaching skills results in an increase in appropriate behaviors and a decrease in self-stimulatory behavior. We also try to understand and meet any sensory needs, which sometimes precipitate behavior difficulties. Your staff is well trained in behavior strategies and interventions, and may use strategies such as correction, redirection, counseling and selective inattention when recommended by a curriculum or behavior specialist. The clinical specialist or designee must approve the more restrictive procedures of suggested or required relaxation. Both involve suggesting or requiring a child and a staff member to retreat to a quiet, low stimulation area to relax. Once calm, the child is returned to previous setting. These strategies are used to help a child calm down when over-stimulated or agitated. If a child needs these interventions, a functional analysis will be conducted by the Autism staff and if necessary an appropriate behavior plan may be implemented if approved by the parents and the clinical team. Passive Physical Holding Defined Since even in a carefully planned individualized program, a child's behavior can become self-injurious or dangerous to others, all Friendship House Staff are trained in "Safe Crisis Management." Should that happen, your child's staff may need to employ a passive physical hold. A formal course of study known as "Safe Crisis Management" is used by Friendship House and has been approved by the Pennsylvania Department of Public Welfare's Office of Children, Youth, and Family Services. This behavior management program teaches appropriate crisis intervention, de-escalation and behavior management techniques. This mandatory course is offered monthly for all direct care staff, who are re- certified at least once a year. Passive physical holding is the least desirable form of intervention and is only used when a client presents a risk of self harm or harm to others. Passive physical holding restricts a client from moving all or part of his or her body. Clients are released from the hold when they have regained control and return to the environment after a life-space interview. There are potential risks to both the client and staff in the use of physical holding, for example, the intensity of the client's resistance to the hold, the physical environment where the hold takes place and the unavoidable physical contact of the individuals involved. These risks could range from minor scrapes or abrasions to more serious injury despite staff's attempts to implement the holding process in a safe, protective and caring manner. Physical holdings are prohibited for clients when medical documentation indicates that he or she will be adversely affected by this technique or used in a punitive manner. Consent The Friendship House behavior management interventions have been explained to me/us. I/We have read the statements above and have had my/our questions answered to my/our satisfaction. I/We fully understand and consent to the use of passive physical holding as behavior management interventions, if deemed necessary by Friendship House staff to assist my child. I/We are not aware of any physical health problems that would prohibit the use of passive physical holding by Friendship House staff.

6 Client Grievance Procedures Page 1 of 2 Purpose Friendship House has established the following procedures to help resolve client grievances without fear of retaliation. Client Grievance Procedure If the client is unable to resolve his/her grievance, he/she has a right to a meeting with a program supervisor. The client also has the right to meet with and discuss the grievance with the Friendship House Clients' Rights Advocate. This person can: Help clients understand their rights. Advocate for clients regarding grievances,and Help clients access the advice and advocacy of organizations outside of Friendship House. Clients shall receive a thorough and fair review and evaluation of their grievance or grievances with a decision being rendered as soon as possible but within 48 hours after the filing of the complaint. If, after the informal meeting, the client still feels the grievance is unresolved, he/she can put in motion by writing to the agency a formal grievance listing the facts and evidence relative to that grievance. The written grievance will be given to the next person in the chain of command not involved in the process so far, which may be the Program Director or the President or designee. In any event, all formal written grievance procedures will be sent to the President or designee at first writing. The written material must be received by the agency five (5) days preceding the hearing date. The hearing and all information will become a part of the clinical record. If, after the hearing with the Program Director, the client continues to feel the issues are unresolved, a hearing is to be given by the President or designee. All facts and information relative to the grievance and put into writing by the agency staff involved should be received by the President or designee no later than five (5) days preceding the hearing date. The President or designee will also receive the formal grievance documentation. The hearing and all information is to be documented by the President or designee and will become a part of the clinical record. In the event the client is dissatisfied with the hearing with the President or designee, the matter is referred to the Board of Directors Chairperson who decides on its disposition. In some cases where public funds are supporting the service to which a grievance is made and the client is not satisfied with the decision made by the President or designee, he/she should be informed of his/her right to appeal the decision of the agency to the placing agency or any other involved agency. If you feel that you have been discriminated against on the basis of your race, color, religious creed, disability, ancestry, national origin, age, gender, sexual orientation, Limited English Proficiency (LEP), or ability to pay, you have the right to contact and/or file a complaint, at any time during the course of the grievance process, with any of the following: Friendship House Office of the President 1615 East Elm Street P. O. Box 3778 Scranton, PA Clients Rights Advocate Friendship House 1615 East Elm Street P. O. Box 3778 Scranton, PA The Advocacy Alliance 846 Jefferson Avenue P.O. Box 1368 Scranton, PA Pennsylvania Human Relations Commission 711 Philadelphia State Office Bldg Spring Garden Street Philadelphia, PA Pennsylvania Human Relations Commission Harrisburg Regional Office Riverfront Office Center 5th Floor South Front Street Harrisburg, PA U.S. Dept. of Health & Human Services Office of Civil Rights Suite 372, Public Ledger Bldg. 150 S. Independence Mall West Philadelphia, PA Bureau of Equal Opportunity Department of Public Welfare Southeast Regional Office 1105B State Office Bldg Spring Garden Street Philadelphia, PA Bureau of Equal Opportunity Department of Public Welfare Northeast Regional Office 331 Scranton State Office Building 100 Lackawanna Avenue Scranton, PA Bureau of Equal Opportunity Department of Public Welfare Room 521 Health and Welfare Bldg. P.O. Box 2675 Harrisburg, PA

7 Client Grievance Procedures Page 2 of 2 Community Care Behavioral Health 72 Glenmaura National Boulevard Moosic, PA Wayne County Human Services Agency 323 Tenth Street Honesdale, PA (570) or Lackawanna Susquehanna Counties Mental Health & Mental Retardation Program 135 Jefferson Avenue, 3rd Floor Scranton, PA Office of Mental Health and Substance Abuse Services Scranton State Office Building 100 Lackawanna Avenue Scranton, PA The above items have been fully discussed with me and I am in agreement with them: (Please Initial) I have received a copy of these Grievance Procedures. Client Signature Date Time

8 Client Rights and Responsibilities Page 1 of 3 Purpose To support and protect the fundamental human, civil, constitutional and statutory rights of all clients. Friendship House will recognize, respect and fully inform all clients and their parents / guardians in writing and in a language or manner they understand of the following rights and responsibilities: Rights 1. You have the right to considerate, respectful care and to expect reasonable continuity of this care. 2. You have the right to give informed, written consent prior to the start of care and treatment, or if you are a minor, to have your legal guardian give informed, written consent. Informed consent is based on an explanation of the care and treatment procedures to be provided, any known risks associated with the procedures, and alternative care and treatments available. Care and treatment may be provided without informed consent in life-threatening situations and instances when care and treatment is required by law. 3. You have the right to retain and exercise to the fullest extent possible all the constitutional, civil and legal rights to which you are entitled by law. 4. You have the right to be informed of the names, qualifications and functions of all care and treatment staff who are providing services to you. 5. You have the right to expect that all communications and records pertaining to your care will be treated according to the laws governing confidentiality. 6. You have the right to participate in the development and approval of your own care and treatment plan. 7. You have the right to fully informed consent prior to the prescribing of psychotropic medications. 8. You have the right to fully informed consent prior to participating in research. There is no penalty for refusing to participate in research. 9. You have the right to voice grievances and make recommendations and/or suggestions with regard to your care and treatment and to be advised of the result of the consideration of your grievance within a reasonable amount of time. You have the right to meet with Friendship House's Clients' Right Advocate to discuss any grievance. This person can: Help clients understand their rights. Advocate for clients regarding grievances,and Help clients access the advice and advocacy of organizations outside of Friendship House. 10. You have the right to care and treatment without discrimination based on your race, color, religious creed, disability, handicap, ancestry, national origin, age, LEP (Limited English Proficiency), sex, sexual orientation or ability to pay. 11. You have the right to care and treatment within the least restrictive environment possible. 12. You have the right to know the cost of your care and treatment. 13. You have the right to know that you and your belongings may be searched for contraband and / or weapons. 14. You have the right to refuse to receive care and treatment from Friendship House unless involuntarily committed. 15. You have the right to communicate with other by telephone subject to reasonable facility policy and written instructions from the contracting agency or court, if applicable, regarding circumstances, frequency, time, payment and privacy. 16. You shall have the right to visit with family at least once every 2 weeks, at a time and location convenient for the family, the child and the facility, unless visits are restricted by court order. This right does not restrict more frequent family visits. 17. You have the right to receive and send mail: (1) Out going mail may not be opened or read by staff persons. (2) Incoming mail from Federal, State or county officials, or child s attorney, may not be opened or read by staff persons. (3) Incoming mail form persons other then those specific in paragraph (2), may not be opened or read by staff persons unless there is reasonable suspicion that contraband, or other information or material that may jeopardize the child s health, safety or well-being, may be enclosed, mail may be opened in the presence of a staff person. 18. You have the right to communicate and visit privately with attorney or clergy. 19. You have the right to be protected from unreasonable search and seizure. A facility may conduct search and seizure, subject to reasonable facility policy. 20. You have the right to appropriate medical, behavioral and dental treatment 21. You have the right to clean; seasonal clothing that is age appropriate and gender appropriate. 22. You may not be subjected to unusual or extreme methods of discipline which may cause psychological or physical harm. 23. You have the right to practice the religion or faith of choice, or not to practice any religion or faith. 24. You have the right not be abused, mistreated, threatened, harassed or subject to corporal punishment. 25. You have the right to be treated with fairness, dignity and respect 26. You have the right to be informed of the rules of the facility. 27. You have the right to rehabilitation and treatment. 28. You have the right to be free from excessive medication.

9 Client Rights and Responsibilities Page 2 of 3 Responsibilities 1. You have the responsibility to exercise your rights in a mature and appropriate manner. 2. You have the responsibility to help develop your care and treatment goals and objectives. 3. You have the responsibility to participate actively in your care and treatment. 4. You have the responsibility to maintain confidentiality regarding the care and treatment of other clients. 5. You have the responsibility to respect the rights of others in the care and treatment setting regardless of race, color, religious creed, disability, ancestry, national origin, age, LEP (Limited English Proficiency), sex, sexual orientation or socioeconomic status. 6. You have the responsibility to inform staff members regarding life-threatening situations that you may become aware of during the course of care and treatment. 7. You have the responsibility to communicate openly and honestly with others in the care and treatment setting. 8. You have the responsibility to learn the rules and regulations of your care and treatment program. 9. You have the responsibility to respect the property of others while in the care and treatment setting. 10. You have the responsibility to contribute of yourself to the larger external community. 11. You have the responsibility not to have on your person nor in your belongings contraband or weapons including drugs, tobacco products, alcohol, matches or lighters, guns, knives, chains, ropes, mace, etc. 12. You have the responsibility to secure appropriate insurance coverage (i.e., Medical Assistance) for your child within 30 days of his/her admission to a Friendship House Program and to maintain this coverage throughout his/her treatment at Friendship House. It is also your responsibility to present all other insurance coverage and inform Friendship House of any changes in coverage. Civil Rights Compliance Client Awareness In accordance with applicable Federal and State Civil rights law and regulatory requirements, you, as a client, have the rights: To be provided services at this agency and to be referred for services at other agencies without regard to your race, color, religious creed, disability, ancestry, national origin, age or sex. To file a complaint of discrimination if you feel you have been discriminated against on the basis of your race, color, religious creed, disability, ancestry, national origin, age or sex. If you feel that you have been discriminated against on the basis of your race, color, religious creed, disability, ancestry, national origin, age, gender, or ability to pay, you have the right to contact and/or file a complaint, at any time during the course of the grievance process, with any of the following: Friendship House Office of the President 1615 East Elm Street P. O. Box 3778 Scranton, PA Clients Rights Advocate Friendship House 1615 East Elm Street P. O. Box 3778 Scranton, PA The Advocacy Alliance 846 Jefferson Avenue P.O. Box 1368 Scranton, PA Pennsylvania Human Relations Commission 711 Philadelphia State Office Bldg Spring Garden Street Philadelphia, PA Pennsylvania Human Relations Commission Harrisburg Regional Office Riverfront Office Center 5th Floor South Front Street Harrisburg, PA U.S. Dept. of Health & Human Services Office of Civil Rights Suite 372, Public Ledger Bldg. 150 S. Independence Mall West Philadelphia, PA 19106

10 Client Rights and Responsibilities Page 3 of 3 Bureau of Equal Opportunity Department of Public Welfare Southeast Regional Office 1105B State Office Bldg Spring Garden Street Philadelphia, PA Community Care Behavioral Health 72 Glenmaura National Boulevard Moosic, PA Wayne County Human Services Agency 323 Tenth Street Honesdale, PA (570) or Bureau of Equal Opportunity Department of Public Welfare Northeast Regional Office 331 Scranton State Office Building 100 Lackawanna Avenue Scranton, PA Lackawanna Susquehanna Counties Mental Health & Mental Retardation Program 135 Jefferson Avenue, 3rd Floor Scranton, PA Bureau of Equal Opportunity Department of Public Welfare Room 521 Health and Welfare Bldg. P.O. Box 2675 Harrisburg, PA Office of Mental Health and Substance Abuse Services Scranton State Office Building 100 Lackawanna Avenue Scranton, PA Client Signature Date Time

11 Verification of Receipt of Friendship House s Notice of Privacy Practices The child identified above is currently enrolled in one or more programs provided by Friendship House and has the following relationship to me or my agency: Select the most appropriate alternative(s): I am the identified child/adolescent Parent of the identified child A child in the custody of my agency pursuant to a court order Other relationship. Explain: Friendship House has informed me of their practices for protecting health information (electronic, paper and other media) regarding myself and/or my child, as well as their practices related to the disclosure of this information and how I can obtain access to my protected health information. I have had an opportunity to read Friendship House s Notice of Privacy Practices and have been provided a copy of the Notice. I am also aware that if I have any questions, I may contact Friendship House s Privacy Officer at By signing below I am simply documenting the fact that Friendship House has informed me of these practices. Client Date Time The original signed copy of this Verification of Receipt is to be filed in the client s Friendship House Clinical Record or signed electronically and maintained in the Electronic Health Record.

12 Program Evaluation / Outcome Study As part of Friendship House's commitment to provide quality services, we would like to be able to contact you (by survey) after discharge from our programs. This would be a chance for you to respond to how you feel regarding the benefits of our treatment. We use this information to evaluate and improve our services. Please indicate whether this is agreeable with you. Contact can be expected at 30, 90, 180 and 365 days; 18 months; 2 years, and each year thereafter. I will keep Friendship House aware of how I can be contacted for each scheduled contact. YES NO I agree to participate in the Outcome Study. YES NO Client Signature Date Time

13 Consent for Recording / Photo Release Client Name: DOB Consent to Internal Recording / Photography For Supervisory, Training and Clinical Purposes I understand and agree that treatment sessions may be recorded as a tool to assist staff in continuing to improve skills through on-going programs of supervision and education (such as case conferences, team meetings, individual and group supervision, and class presentation). I also understand and agree that sessions may be video recorded to facilitate clinical diagnosis and treatment and to help assure quality of client care. These recordings are confidential, and will be used only for internal supervisory, training and clinical purposes. I understand the nature of this consent and that it is revocable at any time by my written or oral request. Client Signature Date Time Purpose / Consent for Photo Release I/We, the parents(s)/legal guardian(s) of, a minor, and intending to be legally bound, hereby consent and authorize Friendship House, its successors and assigns and any other person or corporation duly authorized by Friendship House, to use and reproduce the above-named individual's photograph(s) (still, moving, or video) for the purpose of explaining the Friendship House program, including general promotion of Friendship House services, fund raising, and advertising. In granting this consent, it is understood that my/our child s full name will be used. However, his/her address or other pertinent information about my/our child or his/her family will not be disclosed. I/We agree that no claim whatsoever of any nature will be made by me/us as a result of consent and authorization granted herein. Client Signature Date Time

14 Permission to Give Standing Order Medication to Non-Residential Clients I understand it is the policy of Friendship House that medication may not be administered without consent, or without a doctor's order. I request and give my permission to Friendship House to allow the following non-prescription medications as needed for minor pains, injuries or illnesses. I understand that the decision to give a medication and the actual administration of medication will be done by Nursing personnel and/or their designee as allowed by PA regulations. All medication is administered under the direction of the physician as indicated on this form. Please INITIAL next to YES if Friendship House may give this medication or NO if you do NOT want this medication given. YES NO For Fever and Pain: Tylenol - children's liquid or children's chewables, juniors caplets or adult tablets. Type and amount per age. Ages 2-3 (24 to 35lbs) 160mg; Ages 6-8 (48 to 59lbs) 320mg; Age 11 (72 to 95lbs) 480mg; Ages 4-5 (35 to 47lbs) 240mg; Ages 9-10 (60 to 71lbs) 400mg; Over age mg (2-325mg adult tablets) YES NO For Fever and Pain: Ibuprofin - ages 12 years and over only 1 or 2 tablets (200mg-400mg) YES NO For Scrapes, Abrasions, Minor Burns, and Small Cuts: Medicated First Aid Spray or Antibiotic Ointment Apply topically and cover with bandage YES NO For Poison Ivy, Bug Bites or Simple Rashes:Calamine Lotion or Hydrocortisone Ointment 1% Apply topically as necessary for local relief of itching. Special Instructions: I release Friendship House and its staff from any liability or responsibility for any injuries or damages that may result from the administration of the medications for which I chose YES. Signature is valid for one year from date. I have reviewed this and am in agreement with the above orders. Physician Signature Date Time

15 Treatment Agreement Page 1 of 2 I / We, the parent(s) or legal guardian(s) of, hereby consent and authorize Friendship House, and any other person or corporation duly authorized by Friendship House the right and permission to provide treatment. By initialing the individual items below and by signing this form, we are providing our informed consent to the initialed items. We understand, however, that our child may not be determined to need all of the services to which we have consented. (Please Initial) 1. Providing mental health treatment to include psychiatric or psychological evaluations and individual/family and group therapies, as well as conducting evaluations for possible psychotropic medications, if clinically indicated as part of treatment. 2. Provide minor medical care, first aid, and medication administration during program hours in accordance with Friendship House policies and procedures. Routine screenings for visual/hearing deficits, growth and development milestones, communicable conditions and immunization updates when applicable. Providing referrals to legal guardian to facilitate holistic health care necessary or desirable for the preservation of the health, safety and welfare of the client as appropriate in accordance with reasonable treatment standards, practices and procedures. Friendship House may provide a copy of relevant clinical record documents when the client needs to receive immediate or emergency medical and/or psychiatric care from a non-friendship House facility or provider. Transportation to an appropriate emergency facility for a life/health threatening condition. 3. Providing an evaluation for holistic services which may include an assessment of the client's needs within the home, school, community, and current placement. 4. We understand that we are responsible for payment for the services provided by Friendship House to our child and to other family members. a. I/We authorize Friendship House to apply for and collect payment for services rendered under any federal or state healthcare plan (including but not limited to Medicaid or Medicare), insurance policies, managed care arrangements, or other similar third party payor arrangement for which we and/or our child are eligible. b. I/We agree that we are responsible to provide Friendship House with all necessary information related to the above healthcare plans and insurance coverages, in order to enable Friendship House to apply for and to collect payment for services rendered. c. I/We agree that I/we are responsible for all applicable co-payments, deductibles, coinsurance and/or non-covered costs and charges. d. I/we authorize Friendship House to release health information regarding our child and/or family to insurers, payors, or others for billing purposes. e. I/we agree that, when permitted by law, I/we are responsible for any outstanding balances not paid by federal or state healthcare plans, insurances, managed care arrangements, or other third party payor arrangements for which we and/or our child are eligible. 5. Transporting the client on trips planned by Friendship House staff including those scheduled for out-of-town. Specific consents will be required for all out-of-state or overnight trips. 6. Providing a variety of therapeutic activities for the enhancement of the client's cultural, recreational, and life skills development. Age-appropriate training about maintenance of good physical health and the prevention of transmission of sexually transmitted diseases including HIV/AIDS is also provided as clinically indicated. 7. Friendship House prefers that the client's personal money, expensive jewelry and other valuables remain at home. Friendship House will not be responsible for any of the client's personal property unless it is entrusted to supervisory personnel for safe-keeping in accordance with Friendship House policy and procedure.

16 Treatment Agreement Page 2 of Friendship House may dispose of personal property or valuables not claimed from Friendship House within thirty days of discharge. Clients are to be discharged by the mutual consent of Friendship House, parents/guardians, and the funding agency upon successful completion of treatment goals. Treatment is ongoing throughout the calendar year and participation in the treatment plan requires consistent attendance. Should the client leave the program against medical advice, Friendship House will make every effort to return the client to program or recommend alternative appropriate treatment services. Any readmissions will be at the discretion of Friendship House. Friendship House staff will contact the client, client's parent and/or guardian during treatment and/or after discharge to review satisfaction and evaluate effectiveness of services. Friendship House may provide a copy of relevant clinical record documents for the continuation of medical and/or psychiatric care when the client needs to receive immediate or emergency medical and/or psychiatric care from a non- Friendship House facility or provider. For Residential Clients Only: 12. Provide client well child/adolescent care in accordance with the standards set by the American Academy of Pediatrics utilizing our on-site Medical Clinic and/or Client's Primary Care Physician. Care to include routine immunizations, routine dental and eye care, TB testing, Laboratory, and X-Rays. Parent or legal guardian of the client will assume financial responsibility for co-payments and/or deductible for medical services rendered if deemed appropriate. 13. Parent/guardian and/or authorized contacts are an integral part of the client's treatment at Friendship House. These contacts may be in the form of therapeutic visits at Friendship House or at home, and include telephone calls and letters. All contacts result from a pre-arranged plan individually designed to meet the best interests of each client and mutually agreed upon by Friendship House, the parent/guardian and the referring agency. Friendship House staff will make a recommendation to the parent/guardian, authorized contacts or referring agency as to the place and frequency of visits. THE FRIENDSHIP HOUSE AGREEMENT HAS BEEN EXPLAINED TO ME. I UNDERSTAND AND AGREE TO ABIDE BY EACH PART OF THE AGREEMENT I HAVE INITIALED. Client Signature Date Time

17 Transportation Release Client Name: Client ID: DOB: I understand my responsibility to be physically present when my child arrives home from Friendship House program. I hereby authorize the Friendship House to release my child to the responsible adults listed below in the event of a family emergency and/or at times when I am unavailable to meet my child at the end of the program day. I have made the persons below aware of this arrangement and they agree to take responsibility. The adults listed are the only authorized individuals the Friendship House can release my child to: 1.(Name): Relationship: Address: Phone #: ( ) - 2.(Name): Relationship: Address: Phone #: ( ) - At the time of release of my child to the authorized adults I will not hold Friendship House responsible for their care. I also understand that if I, or the identified emergency contacts are not present, Friendship House will return my child to the facility and will contact Children and Youth Services. Special Instructions: Client Date Time