Clatsop Behavioral Healthcare Application For Services

Clatsop Behavioral Healthcare Application For Services **Please use black ink only** Today s Date: Reason for your visit today: First Name: Middle Name: Last Name: Birth Name: DOB: SSN: Drivers License #: State of Issue: Primary Phone #: message ok? Y N Alternate Phone #: message ok? Y N Cell Phone #: message ok? Y N Emergency Contact Name and Number: message ok? Y N Physical Address: Street: City State Zip Ok to send mail? Y N Same address for mail? Y N If no, complete mailing address below: Referral Source: Street: City State Zip Ok to send mail? Y N Gender: M F Race: Alaskan-Native Ethnicity: Cuban Other Check all that apply Asian Check all that apply Hispanic-Specific Origin not Specified Pregnant: Yes No Black / African American Not of Hispanic Origin Not applicable Hawaiian / Other Pacific Islander Mexican Other Single Race Other Specific Hispanic Two or more unspecific races Puerto Rican White Additional Races: Check all that apply Alaskan Native American Indian Asian Black or African American Native Hawaiian or other Pacific Islander Other Single Race Two or more unspecific races White Living Status: Check all that apply Alcohol and Drug Free Housing Foster Home (licensed by the county or state) Jail Oxford Home Prison Private Residence (at home) Private Residence (with relative) Private Residence (with non-relative) Other Private Residence Room and Board Residential Facility SUD Residential Facility-- 24 hr treatment for Substance Use Disorder (SUD) BRS Residential Facility -- Youth 17 and older living in Behavioral Rehabilitation Services residential facility CSEC Residential Facility Youth 11 to 18 living in residential care facility contracted by OHA PRTS Residential Facility -- Youth 17 and younger Living in a Psychiatric Residential Treatment Services facility SCIP/SAIP Residential Facility Youth 17 and Younger in a Secure Children s Inpatient Program or Secure Adolescent Inpatient Program SRTF for YAT Residential Facility Young Adult In Transition age 17 to 24 living in residential Program (group home) RTH for YAT Residential Facility Young Adult in Transition age 17 to 24 living in Residential Treatment Program (group home) Secure Residential Facility (SRTF) Any person living in a secured residential facility Residential Sub-Acute Care Facility Living in a secure setting requiring active treatment for diagnosed mental health condition. Supported Housing Supported Housing Housing linked with social services (scattered site) Supported Housing -- Housing program specific to identified population linked with social services (congregate setting) Transient/Homeless Tribal Member: Check all that apply Burns Paiute Tribe Confederate Tribes of Coos, Lower Umpqua and Siuslaw Confederate Tribes of Grand Ronde Confederate Tribes of Siletz Confederate Tribes of the Umatilla Confederate Tribes of Warm Springs Coquille Indian Tribe Cow Creek Band of Umpqua Indians Klamath Tribes Not applicable Other Continued Next Page Application for Services CareLogic 2014 Revised MOTS info Page 1

Marital Status: Check all that apply Divorced Living as Married Married Never Married Separated Widowed Tobacco Use: User Non User Unable to Collect Light cigarette smoker (1-9 cigs/day) Moderate cigarette smoker (10-19 cigs/day) Heavy cigarette smoker (20-39 cigs/day) Very heavy cigarette smoker (40+ cigs/day) Smoking Status: Current Every Day Smoker Current Some Day Smoker Former Smoker Rolls own cigarettes Snuff user User of moist powdered tobacco Chews plug tobacco Chews twist tobacco Chews loose leave tobacco Heavy Tobacco Smoker Light Tobacco Smoker Never Smoker Chews fine cut tobacco Chews products containing tobacco Occasional cigarette smoker Pipe smoker Chain smoker Smoker, Current Status Unknown if Ever Smoked Primary Language: English Other Language: English Need Interpreter: Y N French French German German Mandarin Mandarin Portuguese Portuguese Spanish Spanish Tagalog Tagalog Veteran Status: Yes, Veteran and not specified Branch of Service Legal Status: 180 Day Civil Commitment 30 Day Civil Commitment 90 Day Civil Commitment Aid and Assist (ORS 161.370) DUII Convicted Client DUII Diversion Client Employment Status: Disabled-unable to work for physical or psychological reasons Full Time (35 hours or more) Homemaker Hospital Patient or Resident of Other Institutions Yes, Veteran and Current or Former Active Duty Military Yes, Veteran and Current or Former Guard/Reserve Military Guardianship (Child Welfare) Guardianship (Court) Incarcerated Juvenile Psychiatric Security Review Board (JPSRB) None Not in Labor Force Detail Other Reported Classifications (e.g. volunteers) Part Time (fewer than 35 hours) Retired No, but Current or Former Guard/Reserve Military No Parole Probation Psychiatric Security Review Board (PSRB) Sheltered / Non-Competitive Employment Student Unemployed Occupation: Job Title: Days worked in past 30 days: Education: Number years of school High School Diploma / GED Y N Enrolled in Vocational Training: 6 mos 30 days Household Information: Annual Household Income: $ Number in household under age 18: Principal Income Source: Disability / SSDI None Other Public Assistance Number of individuals in your household: Retirement / Pension / SSI Wages / Salary Application for Services CareLogic 2014 Revised MOTS info Page 2

CLATSOP BEHAVIORAL HEALTHCARE 65 North Highway 101, Suite 204 Warrenton, Oregon 97146 Phone (503) 325-5722 Fax (503) 861-2043 Consent to Treatment Client Name: DOB: I have received information on the Declaration for Mental Health Treatment. This document allows me to make decisions about my care if I am unable to make them because of a mental health emergency. If I wish to complete a declaration, I will speak with my clinician. Consent for photo to be taken for my file; used for identification purposes only. The following documents have been given to me: CBH Client Orientation Packet (Grievance Policy, Consumer Rights, etc.) Treatment Attendance Policy Notice of Privacy Practices Voter s Registration Card Declaration for Mental Health Treatment I understand fully and I now want to freely give my informed consent for myself and/or minor child or legal dependent, to be in treatment at Clatsop Behavioral Healthcare. I hereby consent to participate in the services provided at Clatsop Behavioral Healthcare. I understand that Clatsop Behavioral Healthcare is responsible to continue treatment unless no appropriate care is available or unless I fail to meet my responsibilities as described in the Treatment Attendance Policy. I consent at this time to enrollment at Clatsop Behavioral Healthcare. Client Signature Date Parent or Legal Guardian Signature (If client is under 18 years old) Date Last updated: 2.7.17

CLATSOP BEHAVIORAL HEALTHCARE 65 N HWY 101 Suite 204 Warrenton, OR 97146 Phone 503 325 5722 Fax 503 861 2043 www.clatsopbh.org Treatment Attendance Policy Policy: Clatsop Behavioral Healthcare (CBH) recognizes that in order for individuals to receive the most effective services available, it is essential that each person attend sessions and groups as agreed on in his or her Treatment/Recovery Plan. Our attendance policy is that no-shows or late cancellations may result in termination of treatment. Definitions: 1. A no-show is an unexcused absence from a scheduled individual therapy session or group session. Clients are expected to be on time, and if you arrive more than 10 minutes late this may also be considered a no-show and you may not be seen. 2. A late cancellation means cancelling an appointment less than 24 hours ahead of time (except for legitimate emergencies). Procedures: Absences from treatment, for whatever reason, are taken seriously and must always be discussed at the next treatment session. If need be an absence will be discussed with referring sources, which may lead to unfavorable consequences from the referring agency. If a patient has not been seen for greater than 4 months, prior to scheduling the patient with a Licensed Medical Practitioner (LMP), the receptionist must obtain approval from an LMP. Therapy: If an individual is seeing a CBH therapist and no-shows or is a late cancel to one appointment, a receptionist will attempt to contact the client by phone to reschedule. If the appointment is not rescheduled, the client may receive a letter encouraging reengagement with services and remind individuals of our Treatment Attendance Policy. Initial Page 1 of 4

If an individual is seeing a CBH therapist no-shows or late cancels two or more scheduled appointments, it is an indication that he or she is not committed to the agreed-upon Treatment/Recovery Plan and it may lead to termination of services. A letter will be sent to encourage re-engagement with services and remind individuals of our Treatment Attendance Policy. If there is no response to this letter, treatment services will be terminated. If an individual has received a reengagement letter previously and schedules an appointment but does not attend, this could lead to immediate termination of services. Mandated Treatment: Individuals legally mandated to attend treatment services at CBH might be immediately reported to referents at the time of any no-show or late cancellation. For frequent no-shows or late cancellations, individuals who are legally mandated to attend treatment services may be considered non-compliant and their referent will be notified. Addictions Treatment: Individuals are expected to remain abstinent from alcohol and other drugs of abuse while in treatment unless prescribed by a physician. Treatment is a time to evaluate the relationship with substances of abuse and an objective evaluation is impossible if individuals are actively using any substances of abuse. Individuals will inform their primary counselor of ALL medications they are taking, including over the counter medications, while in treatment. Individuals will present any prescriptions, current or newly obtained to their counselor for verification. Some medications will require coordination with my Primary Care Physician. If treatment is mandated, consent to release confidential information will be obtained and ANY use of alcohol and/or drugs will be reported to an individual s referral source. Because relapses are often part of the recovery process, the treatment team will review treatment level and treatment plan to assist individual in remaining drug and alcohol free. Individuals are expected to refrain from consuming alcohol, drugs, medications (unless prescribed to them and prescription is presented), non-alcoholic beer, cough syrup containing alcohol, mouth wash containing alcohol, as well as anything containing poppy seeds. Individuals are also expected to refrain from consuming or using excessive amounts of alcohol based hand sanitizer. Urine Drug Screens (UA s) taken to substantiate an individual s abstinence may be OBSERVED. UA s are mandatory for treatment compliance. If individuals do not provide a collection on the designated day, their counselor will be notified they were a NO SHOW. Two no shows in a row could be considered a compliance issue. Any results that return as not consistent with normal human urine could be a compliance issue and could result in restarting an individual s time in treatment. Initial Page 2 of 4

Treatment Attendance Policy Continued Licensed Medical Practitioner: Clatsop Behavioral Healthcare prescribers are required by law to monitor an individual s response to medications at least every three months and more frequently if changes are required in an individual s medications. No Call, No Show and Late Cancellations (less than 24 hours prior to an appointment) for psychiatric evaluations and medication followup appointments are indications of lack of commitment to treatment and may lead to termination with the CBH prescriber. PSYCHIATRIC EVALUATION APPOINTMENT o When an individual is referred directly by a Primary Care Physician and fails to show for a scheduled Psychiatric Evaluation the following steps will be taken: 1. The Primary Care Physician will be notified of the failure to show for the scheduled appointment. 2. The Primary Care Physician must submit a second referral to CBH prior to rescheduling the appointment. 3. An individual will not be rescheduled for at least 30 days following the missed appointment. o If an individual is referred by a CBH therapist or counselor and fails to show for a scheduled Psychiatric Evaluation the following steps will be taken: 1. The therapist/counselor will be notified of the failure to show for the scheduled appointment 2. The therapist/counselor must submit a second referral indicating the individual s commitment to attending the appointment. 3. An individual will not be rescheduled for at least 30 days following the missed appointment. o Late cancellation of a Psychiatric Evaluation will be handled as a NO SHOW, NO CALL. However, the LMP has the discretion to approve rescheduling of the Psychiatric Evaluation in the case of a Late Cancellation. MEDICATION FOLLOW-UP APPOINTMENTS o At the time of the first No Call, No Show, the receptionist will place a phone call to the individual to encourage him or her to reschedule. Next appointment available may be up to six weeks later. No refills will be provided until an individual is seen by a prescriber. A brief walk-in time first come, first served - is available each week to see a prescriber and obtain a refill on meds once an appointment has been scheduled for follow-up. No changes in meds will be made at the walk-in time. The LMP has the discretion to provide a partial refill (until the next walk-in time) for medications that should not be stopped abruptly o At the time of the second No Call, No Show, a letter will be sent to an individual encouraging re-engagement. No refills will be provided until he or she is seen by a prescriber. Initial Page 3 of 4

o At the time of the third No Call, No Show, a letter closing the individual s chart for the Psychiatric Medication Program only at Clatsop Behavioral Healthcare will be sent. o Frequent failures to attend appointments may result in termination from seeing a prescriber at CBH. o At the time of the first Late Cancellation, individuals are expected to reschedule immediately. No refills on meds will be provided until he or she has scheduled an appointment. Meds will then be provided until the next appointment. o At the time of the second and subsequent Late Cancellations, no refills will be provided until an individual is seen by a prescriber. A brief walk-in time first come, first served - is available each week to see a prescriber and obtain a refill on meds once an appointment has been scheduled for follow-up. No changes in meds will be made at the walk-in time. The LMP has the discretion to provide a partial refill (until the next walk-in time) for medications that should not be stopped abruptly. o Frequent missed appointments may result in termination from seeing a prescriber at CBH. Termination: If your services are terminated for missed appointments or non-compliance, you may reapply at any time. Your application for service will be treated as a new application and your appointment history will be addressed as part of the intake assessment process. If there are any questions about this policy please ask to speak to a supervisor before signing below. I have read the treatment attendance policy and procedures and my signature below attests to my understanding and agreement to the above terms and conditions. If it becomes necessary for me to miss a scheduled appointment I will call as soon as possible, but at least 24 hours ahead of time, to cancel my appointment. Client (or Parent/Guardian s) Signature Date Print Name Client Date of Birth

Clatsop Behavioral Healthcare Medical Information Client Name: Treatment History -- Have you ever received psychological or psychiatric or counseling services before? No Yes Last psychiatric hospitalization: Date: Facility: Have you ever been treated for a substance abuse problem? Yes No If yes, please list your previous treatment experiences: Date Facility / Location MH AD Voluntary? Successful? MH AD Yes No Yes No MH AD Yes No Yes No MH AD Yes No Yes No List all current medications ( Females: Oral contraceptive use?: Y N ) MEDICATION & DOSAGE CONDITION TREATED PRESCRIBED BY Start Date Client s medical care: From whom or where do you get your medical care? Client Doctor s name: Phone: Address: When did you last see your physician? Medical History Have you had any of the following illnesses: (Please Circle) Hepatitis A, B or C Diabetes I or II Thyroid Disease Stomach troubles/ulcers Heart Disease Head Injury High Blood Pressure Seizures Recent weight loss/ gain Glaucoma Loss of consciousness High Cholesterol HIV / AIDS Weeping sores MRSA Dental Problems Please list any drug allergies: Have you ever been hospitalized? No Yes Last Emergency room visit: Have you ever used mood / mind altering substances? Yes No Marijuana Alcohol Methamphetamine Opiates Hallucinogens Have you ever had difficulties with gambling? No Yes Have you any pending/current involvement with the Justice system, DHS, Social Security? Yes No \\CBH-FILES\Users\kathrynm\My Documents\HelpDocs\Internal Policies\Forms\Medical Information page for Intake Packet.doc Page 1 of 1

Clatsop Behavioral Healthcare Release of Information 65 North Highway 101, Suite 204, Warrenton, OR 97146 Phone (503) 325-5722 Fax (503) 861-2043 Authorization for Use and Disclosure of Protected Health Information Name: DOB: ID#: Additional names client or applicant uses: By signing this form, I am allowing my health information to be disclosed and used, as follows: To: Mutual Exchange? From: The authorized individual listed below. If Clatsop Behavioral Healthcare Y/N releasing to a team, list members: 65 North Highway 101, Suite 204 Warrenton, Oregon 97146 Specific Information Authorized for Release: Purpose for Release of this Information: (Initials required in spaces below authorizing) Assessment Coordination of Treatment Treatment Plan Progress Notes Medications used in treatment Urinalysis Report Mental Health Information Alcohol and Drug Information HIV/AIDS related records Financial/Scheduling/Other This consent expires automatically as follows (check one): or (specify): 1 year from date of signature 60 days past case closure I can cancel this authorization at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that information about my case is private, confidential and protected by state and federal law, including Part 2 Title 42 of the Code of Federal Regulations governing the confidentiality of alcohol and drug abuse patient records and Title 45 HIPAA regulations, and that recipients of this information may not redisclose it unless in the exceptional situations cited in the aforementioned regulations. I approve the disclosure only of the named Protected Health Information. I understand what this agreement means. I am signing on my own and have not been pressured to do so. Client Guardian Parent Legal Custody Signature This is a true copy of the original authorization document Page 1 of 2 Date (Agency Staff Person)

To those receiving information under this authorization: This information disclosed to you is protected by state and federal law. You are not authorized to re-release it to any agency or person. For People Who Cannot Write. I understand this form and am completing it voluntarily. I cannot write. I am placing my mark by my name to sign this form. My Mark: Full Name of Client: Date: Witness #1: Address: Witness #2: Address: ***************************************************************************************************** For People Who Cannot Read I have read the form to the client. He/she understands it and signed it voluntarily. Worker's Name: Signature: Date: EXPLANATION Supplying your Social Security Number is voluntary and in general the refusal to supply the Social Security Number cannot be used to deny services. However, it is necessary for identifying some health insurance records. 1. Minimum necessary information must be requested; be specific about what is needed. Do not ask for information you do not need. 2. Family Records. This release covers information about the person signing the form, minor children and information about the family he/she supplied for the record. It would not cover information supplied by other adult family members unless they also sign a release. 3. Children. Minors can consent to mental, emotional or chemical dependency treatment, at age 14. They may sign their own Authorization for Disclosure of PHI forms needed for such treatment. 4. The original of this form will be kept in the file. Copies will be sent to other agencies. The person making the photocopies will sign each copy at the bottom of the first page certifying it as a true copy. The agency receiving the authorization should reject it if there is not a signature by the person who made the copy. 5. Redisclosure. Information received under this authorization should not be redisclosed. Criminal penalties apply to illegal disclosure. Federal regulations (42 CFR Part 2/HIPAA) prohibit further disclosures of any PHI. 6. Revocation. Federal regulations do not allow us to require that the revocation be in writing; it may be revoked orally. 7. Duration. The authorization is valid for 1 year from date of signature or 60 days past case closure, as indicated on page 1 of this release. 8. Guardianship/Custody. If the signatory is a guardian, a copy of the guardianship paper must be attached to this authorization disclosure. Similarly, if an agency has custody, and their representative signs, the custody order should be included. 9. This is a Voluntary Form. However, refusal to allow the Authorization for Disclosure of PHI may adversely affect eligibility determination and may prohibit the coordination of services and treatment. 10. I affirm that everything in this form that was not clear to me has been explained and I believe I now understand all of it. 11. Signature of client or his/her personal representative Date Printed name of client or personal representative Relationship to the client 12. I acknowledge that I received a copy of this completed form. I, the requestor of the information specified overleaf, have discussed the issues above with the client and/or the client s personal representative. My observations of the signatory s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Page 2 of 2