After completing the entire document, you must save the document as a PDF in order to email the documents to us.
To do this:
1) Click the blue "Print Form" button.
2) In the print menu, change the designated printer to "Save as PDF". Then save the document somewhere easy to access.
3) Email the saved PDF to nick@acmecounseling.com

CLEAR FORM
PRINT FORM

ALL the information below MUST be read and understood before treatment begins

1. Attendance is key! Rescheduling, canceling, and demanding your schedule be accommodated for is not conducive to your success. We are not interested in excuses, as we have already heard them all. Completing treatment should be a main priority.

          - Two (2) unexcused absences revokes your privilege to schedule appointments, and you must show up during Open Office Hours on Wednesdays.

         - Three (3) reschedules will restart your treatment, and your referral source(s) will be updated.

2. Our lab uses “leak-proof”containers and the latest technology to check for alterations. Insufficient amounts, dilute samples, or any other abnormality will be counted as a positive analysis, result in your treatment restarting, and will be reported to your referral source(s).

         - YOU ARE RESPONSIBLE FOR WHAT GOES IN YOUR BODY. Poppy seeds, liquid OTC cold/flu medication, and other substances can result in a positive urinary analysis. Included is a list of “harmless” substances you must abstain from to avoid risk of restarting treatment.

         - Do NOT hydrate two (2) hours before submitting a toxicology sample. Do NOT consume more than 8oz of fluid four hours before a sample. These will result in a dilute sample and be considered positive.

         - Do NOT miss an appointment after a holiday. We know this trick.

         - Drugs do not “magically” get into a toxicology sample. We both know the truth.

         - Spice, Kratom, and other“legal” mind altering substances are tested for. The government feels it still shows a substance issue and results in an extension.

3. If you are here for mandated treatment, that is your issue… Additionally, asking questions like, “how much longer do I need to do this?” or, “how many sessions do I have left?” is a sign you may need extended treatment, and may have it enforced thusly.

4. Millennium Health is our toxicology contractor. They may send you a bill. Acme may be able to help with questions and/or a resolution.

5. We are out of network for all private insurances. We will not bill them. You may contact your insurance for reimbursement on your own.

6. You MUST inform us of any change of address for billing purposes.

7. Having a poor attitude is not conducive to a healthy recovery environment. If your behavior towards Acme, its staff, or its clients is deemed unacceptable, you will be terminated and asked to seek services elsewhere.

8. It is the ethical responsibility of Acme to notify your referral source(s) of any positivetoxicology samples, as well as any “suspicious,” or, “out of the ordinary,”behavior.

9. Your “Outpatient Recovery Time” starts after you submit your first negative toxicology sample. Ask if you do not understand.

10. This is not a “90-day Program.” 90 days is the MINIMUM amount of time a person can be in Level 1 treatment as per Oregon Administrative Rules 309-019-0195 (1)(A)and (4)(C). We have only ever had ONE person complete in exactly 90 days.

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Client Registration Form (1)

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Client Registration Form (2)

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Client Orientation Overview

Our goal is to provide you the best treatment services possible. We know that successful treatment is a result of a partnership between counselor and client. In order to accomplish this, we at Acme Counseling take these relationships seriously. We keep up-to-date on the most current information and training available to provide you with the best experience possible.    

We believe that the best practices in counseling include:

         - Involvement of significant other in the treatment process

         - Completion of a full year of treatment services, including aftercare

         - Development and implementation of client specific treatment plans

         - Ongoing, regular, and frequent attendance of support meetings (AA, NA, SOS, etc.)

         - Communication with your other healthcare providers (medication providers, primary care physicians, community partners, etc.)

Current research demonstrates that individual sessions and group therapy are the most effective means of accomplishing goals within counseling. We take our time to craft unique treatment plans for each client that include one (1) or both of these aspects.

Most clients seek treatment to make a positive change in their lives, while some are mandates to receive services by another organization. We are happy to have mandated clients and feel they add value to the treatment experience of all our clients. However, any client who is detracting from the experience of others will receive a brief conference and be given ample opportunity to modify their behavior. If the detracting behavior continues, the individual in question will be asked to seek treatment from another provider or be placed on a modified treatment plan until the individual can change their behavior.

This page serves as an orientation overview; there are many more pages of information. Please take a few minutes to read the entire enclose packet. If you have any questions, staff members are ready and able to help with anything you need.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Overview of Services

Individual Sessions

You and your primary counselor will create a schedule for the two of you to meet and review treatment progress and any assignments given to you as part of the treatment process. This is also a time for you to process with your counselor any issues or concerns you may have in your recovery and personal experiences.

Group Therapy

Studies have demonstrated that group counseling sessions are an effective tool to assist chemically dependent people. Group sessions at Acme Counseling are facilitated by a qualified clinician who facilitates the group member in giving and receiving feedback from peers. To assist your recovery and the group process, it is expected that you are abstinent from all non-prescribed drugs, are willing to give feedback,and are willing to share your feelings and experiences. Your primary counselor is prepared to help you with any concerns you may have regarding the group process. Group sessions at Acme Counseling are offered five (5) times per week.

Toxicology Sampling

Urine Analyses (UA’s for short) are employed to verify your abstinence from all non-prescribed drugs and are a measurable tool to monitor the success of your treatment. If one is unable to reach cessation from alcohol and non-prescribed drugs, successful treatment is stifled. UA’s are used as a measure of your success and progress while in treatment. UA’s are to be delivered when requested by Acme Counseling staff. Try to arrive early for individual and group sessions for UA’s. Prior to going to the restroom at the Acme Counseling facility, check-in at the front desk to see if you need to submit a sample. If so, Acme Counseling staff will walk you through the documentation, chain of custody, and procedures (if needed). The refusal of a sample will be considered admission of chemical use.

Family Sessions

This a time for you, your primary counselor, and family (and/or supportive persons) in your life to meet and discuss the changes made or needed to support your recovery.

NOTICE

If you are deemed intoxicated at any mandatory session, that session will not count towards completions of your mandatory treatment and you will be asked to leave. You may also be found in noncompliance of the requirements mandated by the organization mandating your treatment.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Philosophical Approach to
Providing Service & Support

Acme Counseling subscribes to the belief that treatment for both mental health and A&D can be served utilizing a holistic approach. To provide you with the best treatment experience possible we hire qualified staff who are dedicated to client care, approach clients with respect and dignity, and provide and atmosphere of humor and self-empowerment.Every effort is made to provide you with the best practices and most up-to-date research-based information.

Within your journey at Acme Counseling,you will be asked to attend group counseling sessions, individual sessions with your primary counseling, develop measurable outcomes and workable relapse prevention plan, and/or attend community-based recovery support groups.

As a part of your experience here you may be asked to attend community-based support groups, seek medical advice/attention, include family and other support members in your treatment process, or be referred to community assistance such as Vocational Rehabilitation, employment services, the JOBS program, and/or academic institutions. As you progress in your treatment, we encourage you to invite family members and friends along in your journey.

We hope at Acme Counseling, you will have appositive growth experience. To assist you in your recovery and goals, it is essential that you have full and total abstinence from all non-prescribed substances. This may include alcohol, products which contain alcohol, and any other drug that is mind or mood altering. Treatment staff will assist you as you progress in your stabilization via a structured treatment format and ongoing life skills training.

Each client is an individual. We understand that a one-size-fits-all approach doesn’t make sense when dealing with complex human emotions and the unique lifestyles that we all hold. To the best of our ability, Acme Counseling will attempt to modify our structured treatment services to your individual needs.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Infectious Disease Risk
Assessment (IDRA) (1)

Everyone is worried about AIDS. While most people aren’t at risk for AIDS, some people are at an increased risk and need to make changes to avoid getting infected or spreading infection to others. To help figure out if you have an increased risk for HIV, the virus known to cause AIDS, please answer the following questions:

If you answered No to all these questions, you are not at increased risk for AIDS.
If you answered Yes or Unsure to even one (1) question, you may be at risk for AIDS.

The following questions are asked to help with treatment planning. It is not required that you answer them to participate in assessment and/or treatment.

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Infectious Disease Risk
Assessment (IDRA) (2)

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Patient Health
Questionnaire (PHQ-9)

Over the last two (2) weeks, how often have you been bothered by any of the following problems? (Check the number that best applies)

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Mental Health Screening Form III
(MHSF-III)

Please note, each item refers to your entire life history. This is why each question is headed by, “Have you ever...”

Check Box if YES
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Informed Consent: Acme Policy

As a client of Acme Counseling, either mandated (Driving Under the Influence of Intoxicants, Minor in Possession, Professional Care Services, etc.), or by your own choice, you recognize by signing below that your entry into Acme Counseling is voluntary. You may end your treatment at any time, though there may be possible consequences of failure to comply with legal or other mandates.

Your signature below indicates the following:

• You have received an Acme Counseling Orientation Packet, which included:

        - A copy of our fee schedule

        - A copy of your rights as a client

        - A copy of the notice of privacy and confidentiality

        - A copy of the grievance procedure

        - A copy of the formal grievance form.

 

• You were given the opportunity to have all the above explained to you before you signed the paperwork.

• You have read, understand, and agree to abide by all rule, regulations, and guidelines of this facility.

• You understand that this facility is not responsibly for any loss or damage to my personal property.

• You will not hold the facility liable for any accident or injury which may occur while on facility property.

• You consent voluntarily to attend treatment at Acme Counseling.

• You understand that you are financially responsible for your treatment.

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Informed Consent: HIPAA

Individuals seeking services at Acme Counseling are protected by the Federal laws of HIPAA (Health Insurance Portability and Accountability Act) Notice of Privacy & Confidentiality Rights &Procedures.

Some highlights from HIPAA include:

         • You may not admit to, acknowledge, or inform anyone or any agency that another individual is participating at this facility.

         • You may not discuss, present, or share any information about any clients outside this facility that would breach the client’s confidentiality or anonymity.

         • You may not release any information, verbally or written, regarding any person without both a signed consent to release information by the person involved and expressed written permission of the Executive Director of Acme Counseling

Any breach of this above agreement will result in the termination and/or disassociation from this facility and may result in legal action being taken.

My signature below certifies that I have read and understand the policies on confidentiality and anonymity, and I agree to abide by this policy.

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Fee Agreement

This fee agreement contract is between myself and Acme Counseling, LLC (Acme Counseling). This contract will supersede any previously-dated fee agreement contract.

By signing below, I acknowledge that I have read, understand, have had an opportunity to ask questions about, and agree to the following:

• Acme Counseling is a ‘Fee for Service’ business. Payment is due at the time of each appointment. Withholding payment before services are rendered will result inservices being terminated and the ability to reschedule will be revoked.

• Acme Counseling has presented me with a concise list of services and associated fees.

• If I do not make payments towards my balance for 30 consecutive days, my bill will be sent to a collection’s agency.

• It has been explained to me that a 24-hour notice is required for cancelling for rescheduling. 24 hours means 24 full hours, not just the previous calendar day.

          - Leaving a voicemail and/or sending an email counts as proper contact.

• Failure to show up and/or reschedule within the required 24-hour window will result in a $50 charge that must be paid before rescheduling.

• Under OAR 309-032-1505 (129b), services cannot, and will not, be deemed completed until my balance is paid in full.

• I am solely responsible for the balance of my bill.

• I must inform Acme Counseling of any change to my contact information, such as but not limited to: mailing address, phone number, email address, fax number.

• If utilizing OHP, I am responsible for keep my insurance up to date and to report any change in status to Acme Counseling.

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Fee Agreement

Service

Fee

Specific Notes

Intake Assessment (ASAM)
$200
Session lasts up to 2 hours
Mental  Health Assessment
$200
Session lasts up to 2 hours
DUII/A&D Individual Session
$100
Session lasts up to 50 minutes
Mental Health Individual Session
$125
Session lasts up to 50 minutes
DUII & MIP Information Program (flat-rate)
$850
This program can be modified by the clinician as the need arises.
Consultation
$60
Charged upon contact. Then every ten (10) minutes after that.
Court Appearance Fee
$1500
Per appearance/day
Missed Appointment/Late Cancellation
$50
Applied if not properly canceled or rescheduled 24 hours in advance and must be paid before rescheduling
After Closure Paperwork
$10
Price per page upon request by a client who is closed or completed
Non-Sufficient Funds Check
$80
Per NSF check
Collection's Fee
X
Assessed by collection’s agency
Urinary Analysis
X
Billed through Millennium Health
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Rescheduling Regulations &
Client Prescription Responsibility

Individual Sessions

As per your treatment plan, you will attend all scheduled individual appointments.

        • You are required to give a 24-hour notice to cancel or reschedule an appointment.This means 24 clock hours, and not just the previous calendar day.

        • Two(2) missed sessions without proper notice will result in:

                 - The restarting of your treatment program. (mandated services only)

                 - An update of non-compliance to any and all legal referrals. (mandated services only)

                 - The inability to schedule appointments. We have walk-in spots open Wednesdays at 1pm for those who cannot schedule. (applied at office discretion)

        • Three(3) consecutive missed sessions, for any reason, will result in the termination of your services, you will be barred from any future services at Acme Counseling, and any and all legal referrals will be notified.

Group Sessions

You and your counselor will determine which group sessions (if any) are right for your treatment.

        • DUII Rehabilitation, Outpatient, and most other mandated clients will attend at least 14 group sessions within a 17-week period. Failure to meet this requirement will result in your treatment restarting.

        • Information Program clients must attend four (4) consecutive group sessions. Failure to meet this requirement will result in your treatment level raised, and you will be placed in the 90-day minimum program.

Client Prescription Responsibility

        • You must provide a list of all current prescription medications, issued by your primary care physician/pharmacy, to Acme Counseling no later than one (1) week from your orientation date.

        • You must also provide any updates to your medication before your next UA. Failure to meet this requirement will delay your treatment and result in your UA(s) being considered positive.

                 - This does not apply to OTC medications. (See provided list of medications to avoid during your treatment.

 

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Toxicology Information
& Release Form

All urinalysis testing is performed and billed by Millennium Laboratories(Millennium). Millennium will file a claim for services rendered on the date of you screening. As a result, you will receive an explanation of benefits (EOB) from your insurance company. Please note that an EOB is not a bill; it serves to explain the services you received. If a balance is due, you will receive a separate invoice from Millennium stating an amount owed and the date payment is due. Millennium has relationships with an extensive number of insurance networks and offers flexibly payment options to best meet your needs. For more information, call Millennium at 877-451-7337 and ask to speak with a billing specialist.

For clients without insurance: Millennium’s billing department features highly trained specialists who will work with you one-on-one to determine which flexible payment plans are available to you. To learn more, call Millennium at 877-451-7337 and ask to speak with a billing specialist.

Results and account information will be discussed only with authorized company contacts. Individuals seeking services at Acme Counseling are protected by Federal laws of HIPAA (Health Insurance Portability and Accountability Act) Notice of Privacy & Confidentiality Rights & Procedures.

My signature below confirms that I understand the above billing process. I allow Millennium Laboratories to perform testing and communicate with my insurance and Acme Counseling.

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Release of
Information Form

I, 
born, 

Authorize the release and disclosure of information and/or records relating to: ASAM, assessments, DSM, treatment status, referral reports, UA results,attendance, medical and psychological information, and completion status, from Acme Counseling to the person or agency listed below for the purpose of communication and case management.

• This release can be revoked at any time except to the extent that the program which is to make the disclosure has already taken action in reliance on it. This release will expire in one year from the date in which it is signed unless otherwise specified.
• (42CFR Part 2) regulations prohibit re-disclosure of information from alcohol and drug abuse patient records. Though HIPAA requires Acme Counseling to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
• Communication resulting from this release will divulge that I received services at Acme Counseling.
• For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be predicated on my agreement to sign a release.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Release of
Information Form

I, 
born, 

Authorize the release and disclosure of information and/or records relating to: ASAM, assessments, DSM, treatment status, referral reports, UA results,attendance, medical and psychological information, and completion status, from Acme Counseling to the person or agency listed below for the purpose of communication and case management.

• This release can be revoked at any time except to the extent that the program which is to make the disclosure has already taken action in reliance on it. This release will expire in one year from the date in which it is signed unless otherwise specified.
• (42CFR Part 2) regulations prohibit re-disclosure of information from alcohol and drug abuse patient records. Though HIPAA requires Acme Counseling to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
• Communication resulting from this release will divulge that I received services at Acme Counseling.
• For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be predicated on my agreement to sign a release.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Release of
Information Form

I, 
born, 

Authorize the release and disclosure of information and/or records relating to: ASAM, assessments, DSM, treatment status, referral reports, UA results,attendance, medical and psychological information, and completion status, from Acme Counseling to the person or agency listed below for the purpose of communication and case management.

• This release can be revoked at any time except to the extent that the program which is to make the disclosure has already taken action in reliance on it. This release will expire in one year from the date in which it is signed unless otherwise specified.
• (42CFR Part 2) regulations prohibit re-disclosure of information from alcohol and drug abuse patient records. Though HIPAA requires Acme Counseling to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
• Communication resulting from this release will divulge that I received services at Acme Counseling.
• For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be predicated on my agreement to sign a release.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Release of
Information Form

I, 
born, 

Authorize the release and disclosure of information and/or records relating to: ASAM, assessments, DSM, treatment status, referral reports, UA results,attendance, medical and psychological information, and completion status, from Acme Counseling to the person or agency listed below for the purpose of communication and case management.

• This release can be revoked at any time except to the extent that the program which is to make the disclosure has already taken action in reliance on it. This release will expire in one year from the date in which it is signed unless otherwise specified.
• (42CFR Part 2) regulations prohibit re-disclosure of information from alcohol and drug abuse patient records. Though HIPAA requires Acme Counseling to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
• Communication resulting from this release will divulge that I received services at Acme Counseling.
• For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be predicated on my agreement to sign a release.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Release of
Information Form

I, 
born, 

Authorize the release and disclosure of information and/or records relating to: ASAM, assessments, DSM, treatment status, referral reports, UA results,attendance, medical and psychological information, and completion status, from Acme Counseling to the person or agency listed below for the purpose of communication and case management.

• This release can be revoked at any time except to the extent that the program which is to make the disclosure has already taken action in reliance on it. This release will expire in one year from the date in which it is signed unless otherwise specified.
• (42CFR Part 2) regulations prohibit re-disclosure of information from alcohol and drug abuse patient records. Though HIPAA requires Acme Counseling to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA rules.
• Communication resulting from this release will divulge that I received services at Acme Counseling.
• For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be predicated on my agreement to sign a release.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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UA-101
Policies & Procedures

Staying free from illegal substances is only part of keeping your UAs negative.Substances, both legal and illegal, can trigger a positive UA and be problematic to your treatment. You are solely responsible for what goes in your body. There is no such thing as a false positive.

Some legal substances that can result in a positive UA are:

        • Over the Counter (OTC) medications containing alcohol (see list)

        • Beverages containing trace amounts of alcohol (Kombucha, ‘non-alcoholic’ beer, etc.)

        • Poppy Seeds

        • Mouthwashes containing alcohol

Designer Drugs

Substances like Spice, Kratom, Bath Salts, etc., while considered legal, consumption of‘designer drugs’ promotes addictive behavior and is counterproductive to your treatment. If your UA sample tests positive for such substances will result in the restarting of your treatment, and an update of non-compliance to any and all of your legal referrals.

Abnormal and/or Rejected UA Results

All dilute, abnormal, insufficient quantity, leaked, or any ‘out of the ordinary’ UA results will be considered positive and your treatment will restart.

The following tips will help to ensure normal/negative UA samples:

        • Avoid over-hydration and dehydration

        • Fill your UA container at least halfway full

        • Do not consume liquid two (2) hours before submission

        • Screw the lid on your container tightly

Refusal to Provide a UA Sample

           It is your responsibility to provide a UA when requested. Refusal to submit a UA will result in an update of non-compliance to any and all of your legal referrals. Inability to provide a UA during business hours will be considered refusal and will be reported as such.

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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NOTICE OF
TOXICOLOGY POLICY

ALL toxicology samples that are found to be:

Abnormal,

Dilute, or

Quantity Insufficient

are considered tampered or adulterated, and therefore considered POSITIVE.

 

Adulteration of any kind, either inside the body or out, is easily detectable with the newest technologies employed by our laboratory. We have your best interest in mind for completion, so follow your ISSP to success!

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Grievance Policy &
Procedure

Acme Counseling wants any issue between clients and the agency to be quickly resolved. We review all grievances submitted by clients. If you as a client feel that you are being treated inappropriately by staff of fellow clients, please use the following procedures to submit a complaint:

 

A.   Please present your problem to your counselor, either verbally or in writing. Your counselor will discuss your grievance with you to work towards a solution and they will make a notation in your service record concerning the issue.

B.   If ‘A’ is not satisfactory, staff will act promptly to gather all the facts, review with appropriate agency policies,discuss with supervisor(s), analyze the facts, and make a decision.

C.   Staff members shall take necessary action with 72 hours and document the entire process in the client’s file.

D.   Staff members shall notify the client as soon as possible when regarding complaints.

E.    If the client is dissatisfied with the staff members’ answer, action, or timeliness of response, they may submit a written grievance to the executive director of Acme Counseling.

        - You may acquire a Grievance Procedure Form in person from Acme Staff.

F.    The director shall follow the same action steps within 72 hours. The client shall be notified of the decision and advised as to options they may take if still dissatisfied.

G.   If the client remains unsatisfied with the results of this process, they will be referred county and state authorities and resources.

 

 

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.


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Confidentiality Policies
& Procedures (1)

HIPAA Notice of Privacy& Confidentiality Rights & Procedures

This notice describes how clinical information about you may be used and disclosed, and how you may gain access tot his information. Please review it carefully and ask questions if this information is not clear to you.

The Federal Register governing confidentiality of alcohol and drug abuse patient records, the state of Oregon,and the Federal Health Information Portability & Accountability Act of 1996 (HIPAA) require that healthcare providers (and more strictly, chemical health providers) protect your privacy and confidentiality. It is the responsibility of any Alcohol & Drug Treatment center to assure your privacy and to notify you of your rights and the procedures by which your information is protected and to document that you have received this information. Each client will receive a copy of the Notice of Privacy and Confidentiality Rights & Procedures Form at the time of admission to a program. Acme Counseling, LLC reserves the right to change this notice at any time. If there are changes to this notice,you will receive a copy within 60 days. A copy will be posted at each site with the full policy and is available from staff upon request.

RIGHTS

No client identifying information(including your presence in a program) may be released without your informed,signed consent. This include oral as well as written information. This legislation also required that we release only the minimum necessary information to meet the purpose of the release. All material must contain a notification of privacy and confidentiality stating the information cannot be used for any purpose other than that stated and may not be re-released by the receiving party. A court may only receive information from your record with a subpoena and court order.

        • Under Federal Law, you have the right to determine what information is to be shared and for what purpose, with your signature to authorize the release.

        • You have the right to request that Acme Counselling, LLC communicate your medical information to you in a specific way or to a specific location.

        • You have the right to refuse to authorize the release of any information; however if you refuse, you will be advised of the impact this may have on Acme Counseling, LLC’s ability to treat you, to obtain insurance coverage or funding, and how this may result in additional consequences outside of Acme Counseling, LLC (i.e. refusing to release information to your Probation Officer).

        • You have the right to limit information to be released and if applicable, you will be advised how this may impact delivery of services.

        • You have the right to revoke your authorization at any time except as when it has already been acted on.


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Confidentiality Policies
& Procedures (2)

        • You have the right to know what information has been released under your authorization, to review your clinical records within a reasonable length of time following requests, and to receive copies at a reasonable fee upon your signed consent. Request forms are available upon request.

        • You have the right to reasonable notice of changes in the counseling services or charges.

        • You have the right to file a grievance without fear of retaliation if you feel yourrights have been violated or your care has been inappropriate. The Grievance Procedure is posted at each facility and is available upon request from staff.

        • You have the right to choose from available counselors and to change counselors after services have begun within the limits of health insurance and other payment agreements.

        • You have the right to coordinated transfer when there will be a change in the providers of services.

YOU MAY NOT WAIVE YOUR PRIVACY RIGHTS
(Though there are exceptions)

        • Professional staff is mandated to report all known or suspected cases of child and/or elder abuse/neglect.

        • Staff is required to request a Vulnerable Adult Release of Information form to be signed by all adult clients entering treatment who are considered vulnerable. The purpose is to report neglect or abuse to the County and to develop an abuse prevention plan.

        • Professional staff is required to report if there is substantial reason to believe you may do harm to yourself or others.

        • Professional staff may report information in an emergency situation when the client is unable to provide authorization to assure you receive appropriate medical care or other services to address the emergency, or to the Coroners Office in case of death. Staff is required to document the information disclosed and to notify the client or the client’s representative of any disclosures as soon as possible following the emergency.

        • Staff will report crimes committed by clients on Acme Counseling, LLC property or against other clients or staff.

THE FOLLOWING INFORMATION IS NEEDED IN ORDER TO PROVIDE SERVICES

        • Program costs and dates of service provided to you.

        • Determination of your ability to pay for services you receive.

        • Preparation for billing to insurance companies, funding agencies, or to you.

        • Information regarding your problems and their severity in order to determine your need for services from Acme Counseling, LLC or referral to a more appropriate agency if/when it is a service not provided by Acme Counseling, LLC.

        • Diagnosis and goals to be attained through a service/treatment plan.

        • Objectives toward a goal attainment and progress notes in client record, as well as any correspondence regarding your care.

        • A summary or letter at completion of evaluation, counseling, and/or treatment and arrangements for follow-up contact to determine effectiveness of the services you received.


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Confidentiality Policies
& Procedures (3)

        • Case and record reviews are conducted regularly by Acme Counseling, LLC staff for quality improvement purposes.

        • General, non-identifying information to approved researchers trained in collection, maintenance, and research reports as it applies to all laws regarding privacy and confidentiality.

        • The preparation of state and country reports using demographic information for the purpose of funding and licensing.

        • You have the right to choose not to provide the above information, however should you choose not to, Acme Counseling, LLC may not be able to adequately deliver the services you request and/or it may make you ineligible to receive those services.

PROCEDURES

        • All staff is trained upon hire and annually thereafter regarding privacy and confidentiality regulations and of the penalties and consequences is these laws are not strictly enforced.

        • All client records are maintained in a secure room when not in use and may be access by authorized personnel only.

        • All records are maintained for a period of seven (7) years from last contact with the client or five (5) years past the client’s 18th birthday if the client was a juvenile at the time of service.

        • Billing and clinical records are maintained separately.

        • Files are transported between the sites by a bonded courier in locked boxes or by staff upon specific authorization.

        • Any requests for information must be accompanied by a valid release of information(or subpoena and court order) and must be approved by the Support Staff Supervisor, Program Director, or Chief Executive Officer.

        • Violation is a crime and suspected violation may be reported to authorities.

You may report violations to the members of the Program Director. You will not be discriminated against if you present a problem.

Please feel free to contact the Acme Counseling, LLC Program Director at (541) 286-4010 with any questions or concerns you may have. You may also mail Acme Counseling at: 310 NW 5th Street, Corvallis, OR 97330.

Secretary of the Federal Department of Health & Human Services
200 Independence Ave.SW
Washington, D.C. 20201
(202) 690-7000

 

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.

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Individual Rights &
Non-Discrimination Policy (1)

At Acme Counseling, you will be free to exhibit your rights as described below:

• To be treated in a manner promoting dignity and respect.

• To be treated fairly, without regard to race, ethnicity, gender, gender identity, gender presentation, national origin, creed, religion, sex, sexual orientation, or age. Exceptions may be due to program eligibility that is restricted to children, adults or older adults, familial status, marital status, source of income, and disability.

• To be treated without regard to disability, unless such disability makes treatment afforded by the agency non-beneficial or hazardous. Reasonable actions shall be taken to accommodate persons with disabilities within the program.

• To be protected from invasion of privacy, provided that reasonable searches may be conducted – or other means used – to detect and prevent contraband from being possessed or used on the premises.

• To have all clinical and personal information treated confidentially in communications with individuals not directly related with the agency, assuring confidentiality of records consistent with federal and state laws.

• All clients have the right to give written, informed consent for treatment prior to commencement of services.

• To have the opportunity, upon request, inspect their Individual Service Record (in accordance with OAR 309-032-1515, g) within five (5) days of making the request and assuming the cost of duplication. The client will also have the opportunity to make changes and additions to their record.

• To be fully informed, in writing, regarding fees to be charges and methods of payment available.

• Staff who provide voter registration services will not seek to influence an applicant’s political preferences or party registration. Staff will not display any such political preference or party allegiance, such as buttons, expressing support for a particular political party or candidates for partisan political office.

• To not be subjected by agency staff to physical abuse, corporal punishment, or other forms of abuse.

• To be informed of the agency’s grievance procedure.

• To refuse treatment and be informed and accept the consequences of this right, having this explained to you verbally and/or in writing.

• To obtain complete, current information concerning diagnosis, treatment plan, and prognosis in terms you can understand.

• To be informed of any significant alternatives for care and treatment that may exist.

• To have the staff review and respond to your opinions, recommendations, and grievances in a manner that will preserve and foster the therapeutic aspects of conflict resolution and problem solving.

• To not be subjected by agency staff, inters, or students to sexual contact or sexual abuse.

• To participate in your own treatment planning.

• To receive reasonable accommodations for voting and voter’s registration.


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Individual Rights &
Non-Discrimination Policy (2)

• All individuals have the right to participate in their own religious practices and ideas that are consistent with treatment expectation and program rules.

• To receive treatment services in a timely manner, as deemed appropriated with the individuals presenting circumstances.

• When there are barriers to service such as culture, language illiteracy or disability, Acme Counseling will attempt to make reasonable modifications and accommodations unless doing so would fundamentally alter the character and service of Acme Counseling.

• Acme Counseling will attempt to assist those in need of interpreters, material translation to the individual’s method of communication, or provide assistive devices. To not charge clients the costs of the measures for providing the interpreters and to refer clients to another agency if the client’s needs are outside of Acme Counseling’s area of specialization.

• Any client labor performed as part of the client’s treatment plan or standard program expectations or in lieu of fees shall be agreed to, in writing, by the client and must comply with regulations of other agencies sharing oversight of this program.

• No client labor will be performed as part of the client’s treatment plan or standard program expectations or in lieu of fees agreed to.

• Minors may give informed consent when under age 18 and married, age 16 or older and legally emancipated, or age 14 and older.

• To receive medication specific to your diagnosis that has been prescribed to you by your accredited and recognized prescriber.

• To have continued information presented regarding your rights covered by OAR 309-032-1515, as well as having information on policies, procedures, service agreements, and fees provided as well as to have a parent, guardian, or representative assist with understanding this information.

• To have family involvement with service planning, if applicable.

• When legally an adult, to make a declaration for mental health treatment.

• For clients age 14 or older: you have the right to exercise your rights as covered in ORS

109.610 – 109.697, if you are a minor. If committed to DHS see rights in ORS 426.385.

• All clients are allowed to exercise their rights as described above, without reprisal or punishment.

My signature below certifies that I have read and understand the above information, and that I agree to abide by these policies.


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