1675 S. Maple Grove Rd. Boise, ID 83709

Transcription

1 1675 S. Maple Grove Rd. Boise, ID Dear: We appreciate your interest in Community Connections, Inc. and will strive to provide the highest quality of service providing consistency, professionalism creativity, and teamwork. Community Connections, Inc. will excel at stabilizing and maintain the mental health of individuals in need of a more balanced being. We are dedicated to enhancing independence while we encourage self advocacy and provide support for those in need of an advocate. Our commitment to providing highly qualified professionals in conjunction with a wide array of personalized programs will ensure individuals growth and long-term success throughout a life time. We have enclosed an intake application for services; please fill it out completely and return it as soon as possible or bring it to the scheduled intake meeting. Enclosed are releases of information that we are required to have to send for needed information to determine eligibility and allow us to keep the information in our files for program implementation. There will be a release for each of the following items: 1. Department of Health and Welfare 2. Participant s school 3. Participants Physician (Healthy Connection Doctor) 4. Pediatrician (if applicable) 5. Psychologist/Psychiatrist (if applicable) 6. Service Coordination Agency (if applicable 7. PT/OT/SLP agency (if applicable 8. Other Specialists as needed (i.e. neurologist, audiologist, ophthalmologist etc.) 9. Emergency Medical Release Additional forms in the packet include: (These forms are for your information and do not need to be signed, a separate signature page is in the packet for these forms. We will review each form during the intake meeting should you have any questions.) 1. Choice of Providers Information 2. Informed Consent information 3. Information on services to be Received 4. Information on Benefits 5. Risks Associated with Services Information 6. Alternate Forms of Services Available

2 7. Participant Rights Information 8. Protection and Advocacy Information 9. Information on Legal Assistance 10. HIPPA Privacy Statement 11. Complaints, Grievances, and Appeals Information If you have any of the forms from the providers we are having you sign releases for, or any other information you feel will be helpful in providing your Participant with PSR services and/or psychotherapy, please submit them with the application. This will help expedite the process. Once the needed information is received, the Intake Specialist from Community connections will contact you to review your Participant s need and services and schedule an intake meeting. Thank you again for choosing Community Connections as your mental health agency. We look forward to working with you. If we can be of any further assistance, please do not hesitate to call us at Sincerely, Jackie Taylor, LMSW Jackie Taylor, LMSW PSR Program Supervisor/Psychotherapist Community Connections, Inc. If you have any questions regarding what is contained in your service application please feel free to contact us at and we can assist you. Once we receive your application we will begin processing your request

3 COMMUNITY CONNECTIONS, INC Adult Participant Application for PSR Services : Participant s full name (as appears on Medicaid) Also Known as: of Birth: Sex: Social Security Number: Medicaid Number: Street Address: City: State: Zip Code: Major crossroads near home: Mailing Address (if different from above): City: State: Zip Code: Phone number: Alternate Number: Current Living Situations (circle please): Family Home Foster Home PCS Home IFCID Specialized Family Home Supported Living Apartment Correctional Facility Other: Mother: _ Phone Number: Alternate Number: Address (if different from Adult participants): Father: Phone Number: Alternate Number: Address (if different) Guardian: Phone Number: Alternate Number: Address: Service Coordinator: _ Agency: Phone: School: Graduation : Address: Phone: Was the Participant on a special educational program? YES NO If yes, what program? Current Mental Health Agencies, Medication Management, Speech, OT, PT or Personal Care Service Agencies: Previous Mental Health Agencies, Medication Management, Speech, OT, PT or Personal Care Service Agencies: Professionals: Physician: Address: Phone: of last visit to Physician: Specialist: Address: Phone: Counselor: Address: Phone: Speech Therapist: Phone: Occupational Therapist: Phone: Physical Therapist: Phone: Optometrist: Phone: Audiologist: Phone:

4 COMMUNITY CONNECTIONS, INC Adult Participant Application for PSR Services Medical Information Medication (Including PRN) Dosage Time Seizure Disorder: YES NO When: How Often: If yes, what type? Grand Mal Petit Mal Focal Motor Allergies/Special Diet: Assistive Devises (glasses, dentures, hearing aids, wheel chair, PEC, etc.) Communicable Disease: YES NO If yes, what and describe contagious stages: Other Medical/Mental Health Concerns: Diagnosis information: Primary Diagnosis: Secondary Diagnosis: _ Who established diagnosis: (***be sure to sign a release of information for this individual***) What age was the Participant first diagnosed with their disability/mental health diagnosis: Prenatal issues: Complications/illnesses during Birth: Method of Delivery: C-Section Vaginal Unknown Serious past medical issues (non mental health issues): Past Surgeries: Has the Participant been hospitalized for mental health reasons: YES NO If yes, when? Where? How Long? What caused the hospitalization? Describe the Participant s current medical health?

5 COMMUNITY CONNECTIONS, INC Adult Participant Application for PSR Services Developmental History: Record the age of the milestone Rolling Over: Sitting: Crawling: Walking: First Words: Toilet Trained: Current Developmental Agency: Pervious Developmental Agencies: Participant s Strengths: Participant s needs: Participant s interests (hobbies, recreational, entertainment): Behavioral Information: Current Behaviors (circle all that apply): verbally Assaultive Physically Assaultive Self-Injurious Lying Stealing PICA (eating non-edible items) Property destruction Sexual Misconduct Screaming Defiance Obsessive-Compulsion Harmful to animals Fire setter other/explanation of behaviors: Past Behaviors (circle all that apply): verbally Assaultive Physically Assaultive Self-Injurious Lying Stealing PICA (eating non-edible items) Property destruction Sexual Misconduct Screaming Defiance Obsessive-Compulsion Harmful to animals Fire starting other/explanation of behaviors: Personal History: Describe the Participants past and current ability to socialize with peers: Does the Participant have a history of abuse? YES NO If yes what type? Physical Verbal Emotional Sexual If yes, from whom? When? Family History: Mother: Occupation: Father: Occupation: Siblings/Ages: Who does the Participant reside with? Mother Father Both Neither If not living with natural parents, explain living situation:

6 COMMUNITY CONNECTIONS, INC Adult Participant Application for PSR Services If Participant is not living with both parents, do they have contact with the non custodial parent? YES NO Please explain: Other people currently living in the home with the participant: What other supports does the participant have? (i.e. maternal/paternal grandparents, aunts, uncles, etc.) Does the family have a history of or current physical or mental illness? (Who, what, how treated) Does the family have a history of or current developmental or learning disabilities? (Who, what, how treated) Educational History: (Please list all previous and current) Day Care: Preschool: Elementary: Jr. High/Middle School: High School: Has the Participant any prevocational, vocational, or unpaid work experience? Explain Has the Participant participated in any job skill program? Explain: Financial Resources: Does the Participant receive any state assistance? YES NO If yes, please list: (including amounts) Does the Participant receive SSI/ SSDI? YES NO If yes, how much and who is it paid to?

7 COMMUNITY CONNECTIONS, INC Adult Participant Application for PSR Services Requested Services: Please check the following services you are interested in receiving Individual Psychosocial Rehabilitation Group Psychosocial Rehabilitation Individual Psychotherapy Family Psychotherapy Please give a short description of the major concerns and/or goals that you would like to be addressed through mental health services: Days and Hours Participant is available for Services (this is a general guideline, set hours will be determined prior to services starting) Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: Number of hours per week requested: (5 hours is max for PSR/1 hour max for psychotherapy but we can request more hours from Health and Welfare) Requested Start of Services: Parent/Guardian Participant

8 Acknowledgement of Receipt: By Signing this form, I verify that I have read, understood and received an explanation on the information listed in the categories below and provided with copies of each and understand the information regarding services. This was done pursuant to relevant language in IDAPA code, the Medicaid Provider Agreement and Credentialing standards. 1. PSR Choice of providers ( , ) a. I verify that I desire to receive services. b. I verify that I have been informed of my rights to choose providers. c. I verify that I have selected as the provider to assist me in accomplishing the objectives stated in my individualized treatment plan. d. I verify that I have been informed of my rights to refuse services. 2. Informed Consent To Receive Services. a. Service Information b. Notification of Release of Information to the Idaho Department of Health and Welfare c. Informed Consent of Services d. Participation in Services e. This Consent expires on or whenever interim circumstances or changes in the treatment plan substantially affect the risks or other consequences or benefits reasonably to be expected, or at least annually, or when rescinded by the participant/parent/guardian. I realize that I may withdraw consent and discontinue treatment at anytime without prejudice, and I may require other types of treatment. 3. PSR Information on Services to be Received (Medicaid Provider Agreement E-2) 4. PSR Alternate Forms of Services Available (Medicaid Provider Agreement E-2) 5. PSR Explanation of Benefits (Medicaid Provider Agreement E-2) 6. PSR Explanation of Risks (Medicaid Provider Agreement E-2) 7. PSR Right to Refuse Services (Medicaid Provider Agreement E-2) 8. PSR Participant Rights Information (Medicaid Provider Agreement E-9) 9. PSR Protection and Advocacy Information (Medicaid Provider Agreement E-9) 10. PSR Information on Legal Assistance (Medicaid Provider Agreement E-9) 11. HIPPA Privacy Statement(Medicaid Provider Agreement ) 12. PSR Complaint, Grievance, and Appeal Rights (Credentialing Standards) Participant/Guardian

9 Community Connections, Inc. Release of Records Exchange Form Participant: : Information is to be exchanged between: Community Connections, Inc. & Department of Health and Welfare 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

10 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & School: 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

11 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & Dr: 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

12 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & Service Coordination Agency 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

13 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & SLP Agency: 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

14 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & OT Agency: 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

15 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & Specialist: 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

16 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & DDA: 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

17 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & Other (Please Specify): 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

18 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & Other (Please Specify): 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

19 Community Connections, Inc. Release of Records Exchange Form Participant: DOB: : Information is to be exchanged between: Community Connections, Inc. & Other (Please Specify): 1675 S. Maple Grove Attention: Boise, ID Address: Phone: Fax: Phone: Fax: The following information is being requested: Psychological test results Psychological Evaluation Counseling records Psychiatric test results Social histories Medical history/physical Healthy connections Referral (enclosed) Medical/Social Evaluation Developmental assessments Physical Therapy Evaluation Occupational Therapy Evaluation Treatment Plan/Individual Program Plan Program Implementation Plan SIB-R & Results Academic records School Meeting Notes IEP/504 Plan Speech/Communication Evaluation Early Childhood Service Coordination Plan Vocational Assessments Vocational plans Vocational History Communication Other: Other: Such information may be freely exchanged by the above-designated parities in writing (by fax, electronic mail, or other electronic file transfer mechanisms), by postal delivery, in person or by telephone, but such exchange is limited to the agencies or people listed and to necessary information related to care and treatment, unless otherwise specified. I release the parties involved from all liability arising from such exchange of information. I accept full responsibility for any and all action or consequences that may directly or indirectly result from the release of information. I understand that this release of information is intended to allow me to provide my informed consent for an exception to my confidentiality and the protection of my privacy guaranteed under federal law, including, but not limited to the Federal Privacy Act( P.L ), the Freedom of Information Act (P.L ) and the Code of Federal Regulations (42, Part 2) All information exchanged will maintain confidentiality. This release expires on year from the date signed by the participant, parent and/or guardian. The participant, parent and/or guardian has the right to revoke this release at any time in writing but not retroactive to the release of information made in good faith at the date indicated below or prior to the date consent if revoked. Participant Signature Parent/Guardian Signature Representative of C.C.I.

20 COMMUNITY CONNECTIONS Emergency Medical Care Release I give permission for Community Connection, Inc. to take to a medical (Name of Participant) emergency room or hospital in the event of a minor medical emergency and participant/guardian/care provider is not available to provide assistance or transportation. In the event of a serious medical emergency, 911 will be called. Pertinent medical information, such as medications, seizures, allergies, etc. will be provided, if required, to the medical facility providing the emergency care. It is understood that Community Connections, Inc. is not responsible for the cost or quality of emergency care provided. Community Connections, Inc. is only acting as a Good Samaritan and has no other responsibilities implied or assumed. Participant s Full Name: Medicaid Number: Insurance Number and Police Number: Participant s Signature Parent/Guardian Signature Representative of CCI, Inc Emergency Contact 1. Name (Primary Contact): Relationship: Address: Home Phone: Work Phone: Cell: 2. Name (Secondary Contact): Relationship: Address: Home Phone: Work Phone: Cell:

21 Psychosocial Rehabilitation Services Choice of Providers (Region 3) ( , ) THIS FORM IS FOR YOUR INFORMATION ONLY, SIGNING THE PAGE TITLED, ACKNOWLEDGEMENT OF RECIEPT INDEICATES THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION INCLUDED ON THIS FORM. Participant s Name: of Birth: Provider Name: Caldwell: Abundance Behavioral Health Services Four Rivers Mental Health, Inc Human Supports of Idaho, Inc Idaho Department of Health and Welfare Idaho Migrant Council, Inc Integrity Therapeutic Services WITCO, Inc Council Adams County Behavioral Health Services Emmett Emmett Family Services Fruitland Treasure Valley Behavioral Health Nampa Affinity, Inc. All Seasons Mental Health Centerpointe, Inc Community Outreach Counseling, LLC Life Counseling Center Pioneer Health Resources Renewed Live Center V & T Mental Health Services, Inc Valley View Mental Health Idaho Department of Health and Welfare *Provider List Updated October 8, 2010

22 Psychosocial Rehabilitation Services Choice of Providers (Region 4) ( , ) THIS FORM IS FOR YOUR INFORMATION ONLY, SIGNING THE PAGE TITLED, ACKNOWLEDGEMENT OF RECIEPT INDEICATES THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION INCLUDED ON THIS FORM. Participant s Name: of Birth: Provider Name: Boise About Balance Mental Health, LLC Affinity, Inc Aspen Mental Health Community Partnerships of Idaho Cornerstone Psychological Associates, PLL Human Supports of Idaho, Inc Idaho Department of Health and Welfare (CMH) Mountain States Group, Inc Rocky Mountain Behavioral Health Treasure Valley Community Counseling Garden City Riverside Rehabilitation Meridian Access Living A New Leaf Inroads, LLC Access Behavioral Health Services, Inc All Together Now, Inc Community Connections, Inc Clear Water Rehabilitation Healthy Place Counseling Boise, REG 4 PSR Idaho Department of Health and Welfare (AMH) Leyline Advocates Pioneer Health Resources The ARC Inc Reg. 4 PSR Warmsprings Counseling Center Kuna Kuna Counseling Center Mountain Home Creating Options LLC Reg. 4 PSR Adult Sufficiency Advocates Reg. 4 PSR Weiser Pathways, Inc Provider List Updated October 8, 2010

23 INFORMED CONSENT TO RECEIVE SERVICES THIS FORM IS FOR YOUR INFORMATION ONLY, SIGNING THE PAGE TITLED, ACKNOWLEDGEMENT OF RECIEPT INDEICATES THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION INCLUDED ON THIS FORM. Participant s Name: Medicaid No.: Parent/Guardian was provided with the following information by Community Connections, Inc. on. Service Information: 1. Information on Services to be Received 2. Intended Benefits of Services to be Received 3. Attendant Risks Associated with Receiving Services 4. Alternate Forms of Services Available to Meet Needs 5. Advocacy and Protection Information 6. Information on Legal Assistance 7. Complaint and Grievance Rights 8. Right to Refuse Services 9. Rights when Receiving Mental health Services in Idaho and from Agency 10. Notice of Privacy Practices and Privacy Notice Acknowledgement Form Notification of Release of Information to the Idaho Department of Health and Welfare and other Stakeholders 1. Participant provided with verbal explanation of use of confidential information to be used to assure compliance, collaboration and effectiveness. Informed Consent for Services 1. Evaluation and Assessment 2. Treatment Plan Development 3. Psychosocial Rehabilitation Services 4. Crisis Services Hour Crisis Support Day Review of Services 7. Interdisciplinary Planning Participation of Services 1. Participant provided information and explanation related to the expectation of active participation in all authorized services. Participant understands the service provision is required to meet needs. Types of Services Evaluation and Assessment: Treatment Plan Development: Psychosocial Rehab. Services: Crisis Services: May include personal interview, standardized assessments, Psychiatric evaluation, psychological testing, nutritional assessment, vocational assessment, speech/language assessment, behavioral assessment, mental status exam, psychosocial assessment, occupational therapy assessment, health care assessment. May include regular planning meetings to analyze utilization, phone calls, signatures and active feedback. May include skills training, community reintegration, therapy in the home and community. May include Supports, training, family support emergency intervention for stabilizations, 24 hour consultation.

24 INFORMATION ON SERVICES TO BE RECEIVED Medicaid Provider Agreement E 2 THIS FORM IS FOR YOUR INFORMATION ONLY, SIGNING THE PAGE TITLED, ACKNOWLEDGEMENT OF RECIEPT INDEICATES THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION INCLUDED ON THIS FORM. In 1985 the International Association of Psychosocial Rehabilitation Services (IAPRS) published the following definition of psychosocial rehabilitation as: The process of facilitating an individual s restoration to optimal level of independent functioning in the community While the nature of the process and the methods used differ in different settings psychosocial rehabilitation invariably encourages persons to participate actively with others in the attainment of mental health and social competence goals. In many settings, participants are called members. The process emphasizes the wholeness and wellness of the individual and seeks a comprehensive approach to the provision of vocational, residential, social/recreational, educational and personal adjustment services (Cnaan et al, Psychosocial Rehabilitation Journal, Vol.11, No. 4: April 1988, p.61). Psychosocial rehabilitation is based on a number of assumptions, including two essential ones: People are motivated by a need for mastery and competence in areas, which allow them to feel more independent and self confident. New behavior can be learned and people are capable of adapting their behavior to meet their basic needs. Psychosocial Rehabilitation Principles: Utilization of full human capacity Equipping people with skills (social, vocational, educational, interpersonal and others) People have the right and responsibility for self-determination Services should be provided in as normalized an environment as possible Deferential needs and care Commitment from staff members Care is provided in an intimate environment without professional, authoritative shields and barriers. Early intervention Changing the environment No limits on participation There is an emphasis on social rather than a medical model of care Emphasis is on the client s strengths rather than on pathologies Emphasis is on the here and now rather than on problems from the past Flexibility of structure and service models Non obligatory attendance Support for mobility and choice of service options Active participant involvement in services Support for participant decision making Concentration on quality of relationships and interactions between participants and staff Encouragement of peer support Responsiveness to participants needs Provision of most normal environment Utilization of broad range of skills Active community education Active advocacy Cost effectiveness: both operational and preventative

25 INFORMATION ON BENEFITS Medicaid provider Agreement E 2 THIS FORM IS FOR YOUR INFORMATION ONLY, SIGNING THE PAGE TITLED, ACKNOWLEDGEMENT OF RECIEPT INDEICATES THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION INCLUDED ON THIS FORM. The USPRA has published the following information regarding the benefits of psychosocial rehabilitation services: Psychosocial rehabilitation services promote recovery, full community integration and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs functioning. Psychosocial rehabilitation services are collaborative, person directed, individualized an essential element of the human services spectrum and is evidence-based. They focus on helping individuals re-discover skills and access resources needed to increase their capacity to be successful and satisfied in the living, working, learning and social environments of their choice. It is the principle behind numerous evidenced-based practices. Psychiatric rehabilitation services directly address the high risks that many persons with serious and persistent mental illness experience of hospitalizations, high utilization of emergency room services, low levels of functioning in the community, homelessness, and unemployment. 1. Recovery is the ultimate goal 2. Services may help people re-establish normal roles in the community and their reintegration into community life 3. Services facilitate the development of personal support networks 4. Services facilitate an enhanced quality of life for each person receiving services 5. People receiving services have the right to direct their own affairs, including those that are related to their disablitiy. 6. Culture and/or ethnicity play an important role in recovery 7. Services build on strengths of each person 8. Services are to be coordinated, accessible and available as long as needed. 9. All services are to be designed to address the unique needs of each individual, consistent with the individual s cultural values and norms. 10. Services actively encourage and support the involvement of persons in normal community activities, such as school and work throughout the rehabilitation process 11. The involvement and partnership of person receiving services and family members is an essential ingredient of the process of rehabilitation recovery. As you can see, there are many potential benefits to receiving services. We look forward to assisting you in accomplishing your goals. Crisis Service Availability ( ) PSR agencies must provide twenty-four (24) hour crisis response services for their participants or make contractual arrangement for the provision of those services. For crisis response services, please contact Community Connection s on-call phone at

26 PSYCHOSOCIAL REHABILITATION SERVICES Risks associated with Services (Medicaid Provider Agreement E 2) THIS FORM IS FOR YOUR INFORMATION ONLY, SIGNING THE PAGE TITLED, ACKNOWLEDGEMENT OF RECIEPT INDEICATES THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION INCLUDED ON THIS FORM. Psychosocial rehabilitation is an intensive treatment program designed to reduce the risk of future hospitalization and other impending crises. Our goal, as a rehab treatment provider is to facilitate enough progress among our clients that we are no longer needed. To reiterate, the point of rehab treatment is to eliminate the need for it. This is especially important as the State, who provides funding for this program, views rehab as both intensive and SHORT TERM. RISKS: Remember, all services provided must be clinically appropriate in content, service location and duration. Risks associated with PSR services include, but are not limited to the following items: There are inherent risks associated with receiving services in the home or community. There are risks associated with transportation. Working with various therapists could be a source of frustration and pose some behavioral risks. Therapy is hard! But worth it! You might get worse before you get better. Our agency is here to support you, but hold you accountable to the goals you ve helped develop. There is some risk associated with interacting with others in the community. The ultimate goal is for you to not need services, which can be intimidating to realize. We believe that assuming some of these risks will enable you to make the post progress in the shortest amount of time. We are committed to supporting you in order to minimize the risks to you as you receive services. Please actively participate with us in managing the risks. Remember you are part of a team and we are all striving for the same goal.

27 PSYCHOSOCIAL REHABILITATION SERVICES Alternate Forms of Services Available (Medicaid Provider Agreement E 2) THIS FORM IS FOR YOUR INFORMATION ONLY, SIGNING THE PAGE TITLED, ACKNOWLEDGEMENT OF RECIEPT INDEICATES THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION INCLUDED ON THIS FORM. Psychosocial rehabilitation is an intensive treatment program designed to reduce the risk of future hospitalization and other impending crises. Our goal, as a rehab treatment provider is to facilitate enough progress among our clients that we are no longer needed. We do this by incorporating a wide range of services and supports. Alternate Services and Supports Available: Psychotherapy Group and individual PSR Crisis Services Case management Service coordination Developmental services Vocational services Residential services Personal care services OT, PT, Speech, Audiology Friends Family Churches Civic groups Community organizations We encourage, and will help you cultivate all the supports you need to be successful and accomplish your goals. We will actively pursue unpaid service options to promote optimum independence.