NEW INTAKE PACKET

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice takes effect on October 12, 2002 and remains in effect until we replace it.

1. Our pledge regarding Protected Health Information (PHI):

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of protected health information.

2. Our Legal Duty LEGAL DUTY

Law Requires Us to:

1. Keep your protected health information private. 2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information. 3. Follow the terms of the notice that is now in effect.

We Have the Right to:

1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. 2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.

Notice of Change to Privacy Practices:

1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

3. Use and Disclosure of Your Protected Health Information

The following section describes different ways that we use and disclose protected health information. For each kind of use or disclosure, we will explain what we mean and give an example. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose protected health information. We will not use or disclose your information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us unless it is a non-revocable court release.

FOR TREATMENT:

We may use protected health information about you to provide you with treatment or services. We may disclose protected health information about you to counselors, nurses, technicians, Interns, or other people who are taking care of you.

FOR PAYMENT:

We may use and disclose your protected health information for payment purposes with your written authorization.

FOR HEALTH CARE OPERATIONS:

We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.

ADDITIONAL USES AND DISCLOSURES:

In addition to using and disclosing your protected health information for treatment, payment, and health care operations, we may use and disclose protected health information for the following purposes.

Disaster Relief: We may share protected health information with a public or private organization or person who can legally assist in disaster relief efforts.
Research in Limited Circumstances: We may use protected health information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of protected health information.
Funeral Director, Coroner, Medical Examiner: To help them carry out their duties, we may share the protected health information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Court Orders and Judicial and Administrative Proceedings: We may disclose protected health information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the protected health information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.
Public Health Activities: As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
Victims of Abuse, Neglect, or Domestic Violence: We may disclose protected health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
Workers Compensation: We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.
Health Oversight Activities: We may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.
Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
Appointment Reminders: We may use and disclose protected health information for purposes of reminding you of your appointment.
Alternative and Additional Medical Services: We may use and disclose protected health information about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.

4. Your Individual Rights INDIVIDUAL RIGHTS

You Have a Right to:

Look at or get copies of your protected health information. You may request that we provide copies in a format other than photocopies. We will use the format you request unless it is not practical for us to do so. You must make your request in writing. You may schedule an appointment by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. We may request that you schedule an appointment to review your private health information in order that we may answer any questions you may have. If you request copies, we will charge you $.50 for each page, and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
Receive a list of all the times we or our business associates shared your information for purposes other than treatment, payment, and health care operations and other specified exceptions.
Request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
Request that we communicate with you about your protected health information by different means or to different locations. Your request that we communicate your information to you by different means or at different locations must be made in writing to the contact person listed at the end of this notice.
Request that we change your protected health information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the contact person listed at the end of this notice.

QUESTIONS AND COMPLAINTS If you think that we may have violated your privacy rights, contact the person named above. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint. ACKNOWLEDGEMENT FORM I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Signature *

Please use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date Signed: *

PAGE 01

COMMUNITY COUNSELING CENTER INTAKE FORM

Date: *

Name *

First

Middle

Last

Date of Birth: *//

Age: *

Male
Female

US Citizen? *

Yes
No

Social Security Number: *

Are you satisfied with this situation? *

Yes
No
Indifferent

Ethnicity: *

Hispanic or Latino
Not Hispanic or Latino

(check only one)

U.S. Veteran: *

Yes
No

(Check only one)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Years at this address? *

Phone number?

(leave blank if none)

Are you satisfied with these living arrangements? *

Yes
No
Indifferent

Do you live with anyone who has current alcohol problems? *

Yes
No

Mother’s First Name: *

Client's Birth City: *

Client's Birth State: *

Spouses Name:

(Leave blank if unmarried)

Source of Referral: *

Names & Ages of Children: *

(Type each child's complete name and age. Place commas between each child. If no children, type "none".)

Residence of Children: *

Type each child's name and address. Place commas between each child. If no children, type "none".)

How many children reside with you?: *

How many children are wards of the court?: *

How many children reside with others?: *

Are any of your children currently in foster care?: *

Yes
No

Have you ever abused your children physically/ verbally or left them alone for long periods or left them without food or clean clothing?: *

Yes
No

Do you show your children affection? *

Yes
No

How has your drinking/ drug use affected your family? *

Emergency Contact Person: *

First

Last

Emergency ContactPerson's Phone Number: *

Relationship: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Last grade completed in school *

(drop down to pick grade)

Are you currently enrolled in a school or training program? *

Yes
No

Do you have a valid Driver’s License? *

Yes
No

Do you have an automobile available for use? *

Yes
No

Employment Status: *

(Check one) (Select “Not in Labor Force” if homemaker, disabled, incarcerated, or other)

Primary source of income or support: *

How long was your longest full-time job? *

Usual (or last) occupation? *

How many days were you paid for working in the past 30? *

(Include “under the table” work)

Does someone contribute the majority of your support? *

Yes
No

How much money did you receive from the following sources in the past 30 days?

Complete applicable.

Employment (net income) *

(Write none if you have not worked)

Unemployment *

(Write none if you have not received unemployment)

Public Assistance *

(Write none if you have not received public assistance)

Pension, Benefits, or Social Security *

(Write none if you have not received these)

Mate, Family, or Friends (Money for personal expenses) *

(Write none if you have not received these)

Illegal *

(Write none if you have not received this)

How many people depend on you the majority of their food, shelter, etc.? *

How many days have you experienced employment or school problems in the past 30 days? *

How troubled or bothered have you been by these employment problems in the past 30 days? *

How important to you now is treatment for these employment problems? *

Have you ever been diagnosed based on DSM-IV criteria? *

Yes
No

In the past 30 days, how many were spent in a controlled environment? *

PAGE 2

COMMUNITY COUNSELING CENTER CONSENT TO TREATMENT

I understand that as a client of the Community Counseling Center, I am entitled to the services offered for substance abuse treatment. I understand that recommendations for treatment and referrals will be developed for and will become a part of my file. I understand that I have the right to refuse any or all parts of the recommendations for treatment except for emergency treatment designed to protect the health and safety of myself and others. Before these recommendations for treatment are put into effect, I understand that I have a right to be informed as to the nature and consequences of the recommendations for treatment, the reasonable risks, benefits and purposes of the recommendations, and any alternative recommendations for treatment available to me. I further understand that I may withdraw my consent to any and all parts of the recommendations for treatment and referral, in writing, at any time.

CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal Law Regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser UNLESS the patient consents in writing, the disclosure is allowed by a court order or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Sometimes the Substance Abuse Prevention & Treatment Agency (SAPTA) sends questionnaires to certain clients of our center for the purpose of research and gathering statistics. This gathering of information assists our center in receiving federal money.

Violation of the Federal Law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with the Federal regulations. Federal law and regulations do not protect information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.

FEDERAL LAWS AND REGULATIONS DO NOT PROTECT ANY INFORMATION ABOUT SUSPECTED CHILD ABUSE OR NEGLECT FROM BEING REPORTED UNDER STATE LAW AR APPROPRIATE STATE OR LOCAL AUTHORITIES. THREATS OF SUICIDE OR BODILY HARM TO OTHERS WILL ALSO BE REPORTED. THESE ARE NOT PROTECTED UNDER THE FEDERAL LAW.

See 42 U.S.C 29 Odd-3 and 42 U.S.C. 290ee-3 for Federal Laws and 42 CFR Part 2 for the Federal regulations.

Client Signature: *

Please use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date: *

Parent/ Guardian’s Signature (If Client is a minor): *

Please use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Write N/A into field if client is NOT a minor)

Date: *

PAGE 3

Community Counseling Center Client Complaint Procedure

A client may file a complaint, in writing, within ten (10) days of the occurrence of the incident or discovery of the event to the Chairperson of the Board of Directors of the Community Counseling Center, at 205 South Pratt Avenue, Carson City, Nevada 89701. The chairperson will then appoint a committee of two in order to investigate the client’s grievance within thirty (30) working days and report the findings to the Board of Directors.

The Board will then review and a determination will be made within ten (10) working days to the validity of the grievance and, when necessary, appropriate action will be taken by the Board.

There is no threat of retribution or other adverse consequences to the client as a result of filing a grievance.

CLIENT ACKNOWLEDGMENT

I have read, understand, and been provided with a copy of the above Client Complaint Procedure.

Client Signature: *

Please use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date: *

Parent/ Guardian’s Signature (If Client is a minor): *

Please use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Write N/A into field if client is NOT a minor)

Date: *

PAGE 4

Substance Abuse Prevention and Treatment Agency
Sliding Fee Scale
Policy Statement
July 1, 2010

The purpose of the Substance Abuse Prevention and Treatment Agency (SAPTA) funding of services for abuse of alcohol and other drugs is to ensure that such services are made available to all Nevadans independent of the person's ability to pay. Accordingly, a person may not be denied access to SAPTA-funded services for abuse of alcohol and other drugs due to his or her ability to pay for the service.

Assessment of fees according to a sliding schedule of fees does not, in itself, ensure access to services due to ability to pay because the client may lack the funds to pay even reduced fees. In these cases, no co-pay percentage will be collected.

Any practice which established a fiscal barrier to client access to SAPTA-funded services can result in SAPTA withholding or terminating all or part of the funding to the program operator. Examples of such practices are:

1. Requiring an administrative processing fee be paid prior to access to SAPTA-funded services;
2. Requiring an assessment or evaluation fee to be paid prior to access to SAPTA-funded services;
3. Requiring that a deposit be made towards the anticipated bill prior to access to SAPTA-funded services;
4. Requiring that the person pay his or her fee prior to access to SAPTA-funded services.
5. Termination of services due to failure to pay in a manner other than that specified by SAPTA concerning individuals who are able to pay, but refuse to do so.
6. Failing to inform persons inquiring about availability of services that funded by SAPTA are available independent of ability to pay; and cannot base client's ability to pay on future earnings.
7. Denial of services due to client's ability to pay for additional services or materials which are not funded by SAPTA. For example, if the program design is such that access to SAPTA-funded Level II services requires co-enrollment in un-funded Transitional Housing provided by the program operator, the program operator must make the Transitional Housing service also available independent of client ability to pay. To do otherwise result in tacit denial of access to SAPTA-funded Level II services due to ability to pay.

The foregoing are independent of the client's referral source and independent of whether the client has stated motivation to enter treatment subsequent to assessment. This has important implications for forensic clients:

If a client is seeking assessment solely for the purpose of obtaining a report to a court, the client is still to be provided assessment independent of his or her ability to pay. However, the program may unbundle the report on the findings of the assessment from the assessment itself. The client then is provided assessment independent of ability to pay, but any report to a court on the findings of the assessment is a separately billed service. The program then may choose to prepare and send a report to the court only after the client has paid the program a reasonable fee for doing so. If the program chooses to unbundle court reports as a separately billed service, it is incumbent upon the program to inform the client of this prior to the assessment being conducted.

If a client is court-ordered to treatment, or is in treatment as a condition of parole, reports to verify client participation in, or completion of, treatment, may not be unbundled as a separately-billed service. Client being provided SAPTA subsidized treatment independent of ability to pay must also be provided reports of participation or completion also independent of ability to pay. Such reports or certificates of completion of treatment may not be withheld due to ability to pay.

SLIDING FEE SCALE WORKSHEET/AGREEMENT

AGENCY NAME: *

CLIENT’S NAME: *

UNIQUE CLIENT ID: *

(Write none if not applicable)

Date: *

PROGRAM LOCATION: *

(Write none if not applicable)

As a client of a treatment program receiving funds administered by the Nevada Substance Abuse Prevention and Treatment Agency (SAPTA), you have the right to a determination of fees according to a sliding fee scale that takes into account income and family size. Reduction of your fees according to this scale is contingent upon your providing verifying information. Such documentation should be provided at the intake session at which your share of costs is determined. Indigent clients, including those who are non-citizens and/or homeless may not be able to provide any of the documentation requested below. If you can provide a letter from any other agency, local service provider verifying your status, you will be assessed fees based on $0 income for the provision of services. Should a letter be unavailable, the program’s no documentation policy may be used. No prepayment or deposits can be a condition of any aspects of the services. For further information refer to the Sliding Fee Scale policy.

1. TOTAL ANNUAL INCOME: Identify all income received by you and others residing in the same household during the past twelve months. (Gross money, wages, and salaries before any deductions.)

2. NUMBER IN HOUSEHOLD: *

(Enter number including client.)

Others: Name (first and last), Age, & Relationship to Client

1.

2.

3.

4.

5.

SLIDING FEE SCALE CALCULATIONS: Note the percentage that corresponds to the appropriate income and number in the household. Multiply this percentage by SAPTA unit rate to determine client co-pay.

If you are a non-emancipated minor under 18 years of age, your parent or legal guardian must sign the application. If you are a dependent adult under a conservatorship of estate, your conservator must sign the application.

By signing below, I acknowledge that I have received a copy of this information. I understand that I will be responsible for % of my substance abuse treatment costs. The costs of my treatment will be based on the number and types of services offered me. I can review my costs for treatment at any time. I understand that if my financial situation changes during treatment, revised sliding fee calculations will be made and will be effective for services provided after the date the new scale is signed. I further acknowledge that all information provided by me is accurate to the best of my knowledge.

Client Signature: *

This must be a witnessed manual signature only.

Date *

Witnessed By (program staff):

Signature above must be witnessed and manually signed by program staff member.

Date

SUBSTANCE ABUSE PREVENTION AND TREATMENT AGENCY

PAGE 5

POLICY-HOLDER’S INSURANCE FORM

Name: *

(As shown on Card)

Social Security Number: *

Date of Birth://

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

(Write none if not applicable)

Phone Number: *

(Write none if not applicable)

Place of Employment: *

(Write none if not applicable)

Employment Phone Number: *

(Write none if not applicable)

Insurance Company:

(Leave blank if none)

I hereby authorize the Community Counseling Center, Counselor on record or the billing company, (Sierra Health Billing Service) to release information to my insurance company/ companies the information it/ they need to process my insurance claim(s). I acknowledge that the information to be released may include PSYCHIATRIC, ALCOHOL, and/ or DRUG ABUSE information. These records are protected by Federal Regulations. My signature authorizes release of such information.

Client Signature: *

Please use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date *

AUTHORIZATION TO PAY PROVIDER

I authorize any insurance benefits to be paid directly to Community Counseling Center/ Mary Bryan. I understand that I am financially responsible for the unpaid balance in the event my insurance coverage does not pay this account in full, unless other arrangements have been made with the Community Counseling Center/ Mary Bryan.

Client Signature: *

Please use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date *

Financial Terms and Co-pays:

Fees: $150.00 per session (This includes Individual, Family, Couples, etc.)
$ 50.00 per group for Substance Abuse

As a courtesy we will be glad to bill your insurance, however, the responsibility for total payment remains on the client. Therefore, according to company policy, a fifty percent payment ($55.00 for individuals and $25.00 or $30.00 for groups) is required at time of service. If and when the insurance company provides payment, we will gladly issue a credit for future service or a refund for those who are no longer clients here.

If I have been out of compliance for more than 30 days with the billing agency’s request for payment, legal action may be initiated or a referral of the account to a collection agency may occur.

PAGE 6

Community Counseling Center
205 South Pratt Street
Carson City, Nevada 89701

Financial Status Worksheet

Client Name: *

If client is under 18 years of age, parent/guardian’s will need to complete this form.

Number of Dependents: *

(Write none if none)

Projected Monthly Income:

Projected Monthly Expense:

Job (Self) *

(Write none if none)

Rent/Mortgage *

(Write none if none)

Job (Spouse) *

(Write none if none)

Transportation *

(Write none if none)

ADC *

(Write none if none)

Utilities *

(Write none if none)

SSI *

(Write none if none)

Medical Insurance *

(Write none if none)

Alimony *

(Write none if none)

Groceries *

(Write none if none)

Retirement *

(Write none if none)

Cigarettes/Alcohol *

(Write none if none)

Social Security *

(Write none if none)

Nails/Hair *

(Write none if none)

Vet Benefits *

(Write none if none)

Other *

(Write none if none)

Rent Income *

(Write none if none)

Stocks & Bonds *

(Write none if none)

Child Support *

(Write none if none)

Other *

(Write none if none)

Total Monthly Income *

Total Monthly Expense *

"The above information is a complete and accurate record of my current monthly finances. I understand that it is my responsibility to notify the office if there has been any change. If it is discovered that the sliding fee has been established due to misrepresented information, the full fee will automatically be in effect."

Client Signature: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date *

Parent/Guardian's Social Security #: *

(Complete if signing for minor. Write N/A if not signing for minor)

Parent/Guardian's Date of Birth: *

(Complete if signing for minor. Write N/A if not signing for minor)

Parent/Guardian's Signature (if Client is a minor): *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Write N/A into field if Client is NOT a minor)

Date: *

PAGE 7

COMMUNITY COUNSELING CENTER CONTRACT FOR SERVICES

Group Sessions (90 Minutes)                                                                       $50.00/Substance Abuse
                                                                                                                      $60.00/Domestic Violence Intensive
Outpatient Groups (180 Minutes)                                                                 $75.00
Individual, Couples, Marriage and/or Family Counseling (50 minutes)        $150.00
Evaluations (Drug & Alcohol), Domestic ViolenceIntakes                             $150.00
Court Appearances                                                                                       $250.00/Per Hour
Urine Screening for Alcohol & Drug                                                              $25.00

CONDITIONS

I agree to the following financial conditions for my assessment and treatment by the Community Counseling Center:

1) I understand that the fees listed above are my responsibility unless other written arrangements are made.
2) I have received a copy of the sliding fee scale based on ability to pay.
3) It is my responsibility to report any changes in income.
4) I understand that if I do not keep my scheduled appointments, I may be creating a barrier to treatment for another individual.
5) I understand that I may receive a Urine screen as a part of any evaluation for Substance Abuse or Domestic Violence.
6) IF I HAVE BEEN REFERRED BY COURT ORDER, I AM RESPONSIBLE FOR THE COSTS OF TREATMENT INCLUDING RANDOM URINE SCREENING. FAILURE TO PAY MAY RESULT IN CONTEMPT OF COURT CHARGES.
7) If I discontinue treatment against staff advice, the total amount of my account will become due and payable within ten (10) days of discharge.
8) If I have been out of contact with the Center for thirty (30) days or more without notice, my case will be considered closed and my account will be due and payable.
9) If I fail to comply with the terms of this contract, the Community Counseling Center may initiate legal action or refer the account to a collection agency. I shall be responsible for attorney’s fees and collection expenses.

I have read and understand this contract:

Dated: *

Client Signature: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Parent/Guardian's Signature (if Client is a minor): *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Write N/A into field if Client is NOT a minor)

PAGE 8

MEDICAL QUESTIONNAIRE

Name *

First

Last

Personal or Family Physician: *

(Type N/A if you do not have a personal or family physician)

If the client is under Age 18: Please indicate any prenatal events or conditions that may have impacted this child.: *

(Write N/A if not applicable)

Have you ever had any of the following? Please Check YES or NO

Severe Headaches *

Yes
No

Head Injuries *

Yes
No

Hearing loss or earache *

Yes
No

Hay-fever *

Yes
No

Chronic cough *

Yes
No

Shortness of Breath *

Yes
No

Asthma *

Yes
No

Heart Trouble *

Yes
No

High Blood Pressure *

Yes
No

Rheumatic Fever *

Yes
No

Stomach Ulcers *

Yes
No

Gallbladder Trouble *

Yes
No

Hernia (Rupture) *

Yes
No

Kidney Trouble *

Yes
No

Dislocation of Joints *

Yes
No

Broken Bones *

Yes
No

Bone, Joint Problems *

Yes
No

Rheumatism/ Arthritis *

Yes
No

Back Pain/Injury *

Yes
No

Knee Injury *

Yes
No

Varicose Veins *

Yes
No

Skin Problems or Rash *

Yes
No

Nervous Disorders *

Yes
No

Fainting Spells *

Yes
No

Epilepsy *

Yes
No

Jaundice *

Yes
No

Diabetes *

Yes
No

Cancer *

Yes
No

Tumor *

Yes
No

Anemia *

Yes
No

Complications from Childhood Disease *

Yes
No

ALLERGIES TO MEDICATIONS *

Yes
No

ALLERGIES TO OTHER SUBSTANCES *

Yes
No

Please list all drugs/substances that cause adverse reactions: *

(Write none if none)

Have you ever had a work-less injury or illness? *

Yes
No

Have you ever received compensation for an industrial injury or illness? *

Yes
No

Are you presently under a doctor’s care for any condition? *

Yes
No

Do you have any chronic medical problems which continue to interfere with your life? *

Yes
No

How many times in your life have you been hospitalized for medical problems? *

Describe. (Include o.d.’s, d.t.’s, exclude detox. Write none if none)

Have you had any operations? *

Yes
No

Are you taking any prescribed medications on a regular basis for a physical problem? *

Yes
No

Do you have a pension for a physical disability? (Exclude psychiatric disability) *

Yes
No

(Exclude psychiatric disability)

If you are a female, are you pregnant? *

Yes
No
Unknown

(if male, please check no.)

How many days have you experienced medical problems in the past 30 days? *

(Include sickness and/or physical health problems, exclude alcohol and/or drug induced problems)

Date of last physical examination: *

(Write unknown if unknown)

Name of Doctor: *

(Write none if none)

Date of last Chest X-ray:

(Write in date, if none write none.)

Name of Doctor: *

(Write in date, if none write none.)

Tuberculosis
The following questions are to help you decide whether you are at risk for tuberculosis:

Do you work or live in a correctional institution, nursing home, mental Institution or health-care facility? *

Yes
No

Do you live with or have close contact with someone who has TB? *

Yes
No

Do you use needles to inject drugs? *

Yes
No

Do you have any of the symptoms of TB, which include: coughing, tiredness, weakness, fever, weight loss, or spitting up blood? *

Yes
No

If you answered “yes” to any of the previous questions, you could be at risk of acquiring TB. This disease can cause serious illness or death unless it is treated properly. If you answered “yes” to any of these questions, please contact the Nevada Health Division for testing and more information about prevention and treatment.

Nevada Health Division
4150 Technology Way
Carson City, NV 89706
(775) 684-5900

Acquired Immune Deficiency; Human Immunodeficiency Virus
It is the policy of the Center that medical information related to the positive antibody testing, AIDS related complex (ARC), TB or Hepatitis not be included as part of the client’s record. A client’s personal admission of AIDS in or during treatment sessions may bring to light treatment issues surrounding the disease. It is the policy of the Center to provide education for limiting the spread of HIV. If a referral is needed the counselor will provide it. Early intervention services are available here through any counselor. Please ask for additional information during your intake appointment.

Refer to and circle primary care physician/urgent care/emergency room if 8 or more is marked.

IF YOU ARE AGE 12 OR OLDER PLEASE COMPLETE THE HISTORY BELOW:

What problem areas brought you here today? *

How do you feel we can help you? *

Drug/Alcohol Use History:

First Drug of Choice: *

(If none write none.)

Second Drug of Choice: *

(If none write none.)

Other: *

(If none write none.)

Drug Type/include Alcohol and Nicotine: *

(If none write none.)

Frequency of use per week: *

Amount of use in the past month *

Age of first use: *

Route of Administration *

(Snort, Oral, Smoke. If none write none.)

Were Your Parents or Grandparents Alcoholics or Substance Abusers? *

Yes
No

Client Signature: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date: *

PAGE 9

COMMUNITY COUNSELING CENTER
CLIENT RIGHTS

Client name: *

First

Last

As the client of a program for treatment of abuse or of dependency upon alcohol or other drugs, your rights include, but are not limited to, the following:

1 If the program receives funds from the Substance Abuse Prevention Treatment Agency (SAPTA), you have the right to be provided treatment regardless of whether or not you can afford to pay it, and the program is prohibited from imposing any fee or contract which would be a hardship for you or your family.

2 You have the right to be provided treatment appropriate to your needs.

3 If you are transferred to another treatment provider, you have the right to be given an explanation of the need for such transfer and of the alternatives available, unless such transfer is made due to a medical emergency.

4 You have the right to have your clinical records forwarded to the receiving program if you are transferred to another treatment program.

5 You have the right to be informed of all program services which may be of benefit to your treatment.

6 You have the right to be informed of the name of the person responsible for coordination of your treatment and of the professional qualifications of staff involved in your treatment.

7 You have the right to be informed of your diagnosis, treatment plan, and prognosis.

8 You have the right to be given sufficient information to provide for informed consent to any treatment you are provided. This is to include a description of any significant medical risks, the name of the person responsible for treatment, an estimate of the costs of treatment, and a description of the alternatives to treatment.

9 You have the right to be informed if the facility proposes to perform experiments that affect your own treatment, and the right to refuse to participate in such experiments.

10 You have the right to examine your bill for treatment and to receive an explanation of the bill.

11 You have the right to be informed of the program’s rules for your conduct at the facility.

12 You have the right to refuse treatment to the extent permitted by law and to be informed of the consequences of such refusal.

13 You have the right to receive respectful and considerate care.

14 You have the right to receive continuous care: To be informed of your appointments for treatment, the names of program staff available for treatment, and of any need for continuing care.

15 You have the right to have any reasonable request for services reasonably satisfied by the program, considering its ability to do so.

16 You have the right to safe, healthful, and comfortable accommodations.

17 You have the right to confidential treatment. This means that, other than exceptions defined by law-such as those in which public safety takes priority-without you explicit consent to do so, the program may release no information about you including confirmation or denial that you are a patient.

18 Waiver of any civil right or other right protected by law cannot be required as a condition of program services.

19 You have the right to freedom from emotional, physical, intellectual, or sexual harassment or abuse.

20 You have the right to attend religious activities of your choice, including visitation from a spiritual counselor, to the extent that such activities do not conflict with program activities. The program shall make a reasonable accommodation to your chosen religious activities. Attendance at and participation in any religious activity is to be only on a voluntary basis.

21 You have the right to grieve actions and decisions of facility staff which you believe are inappropriate including but not limited to actions and decisions which you believe violate your rights as a patient. The facility is obligated to develop a grievance procedure for timely resolution of complaints from patients and to post such a procedure in a place where it shall be immediately available to you. You have the right to freedom from retribution or other adverse consequences as the product of filing a grievance.

22 You have the right to file a complaint with the State of Nevada if the facility’s grievance procedure does not resolve your complaint to your satisfaction, and the right to freedom from retribution or other adverse consequences as the product of filing a complaint. Such complaints may be addressed in writing or by telephone to:

Substance Abuse Prevention and Treatment Agency (SAPTA)
Attention: Statewide Program Coordinator
4126 Technology Way, 2nd Floor
Carson City, NV 89706
(775)684-4190

23 You have the right to be informed of your rights as a patient. The foregoing are to be posted in the facility in a place where they are immediately available to you, and you are to be informed of these rights and given a listing of them as soon as is practically possible upon your beginning treatment.

Patient Acknowledgement
I have read, understand, and have been provided a copy of the above Client’s Rights.

Client Signature: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date: *

Parent/Guardian's Signature (if Client is a minor): *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Write N/A into field if Client is NOT a minor)

Date: *

PAGE 10

Mental Health Screening

Instructions: In this program, we help people with all kinds of problems, not just their addictions. This commitment includes helping people with emotional or psychological problems. Our staff is ready to help you to deal with any problems you may have, but we can do this only if we are aware of the problems. Any information you provide to us will be kept in confidence. Please note, each item refers to your entire life history, not just your current situation.

Please check the appropriate answer YES or NO.

1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker, counselor, or spiritual leader about an emotional problem? *

Yes
No

2. Have you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your emotional problems? *

Yes
No

3. Have you ever been advised to take medication for anxiety, depression, hearing voices, or for any other emotional problems? *

Yes
No

4. Have you ever been in a psychiatric emergency room or been hospitalized for psychiatric reasons? *

Yes
No

5. Have you ever heard voices no one else could hear or seen objects or things which others could not see? *

Yes
No

6. (a) Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and making decisions, or thought about killing yourself? *

Yes
No

(b) Did you ever attempt to kill yourself? *

Yes
No

7. Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible event? For example, war, gang fights, fire, domestic violence, rape, incest, car accident, being shot or stabbed? *

Yes
No

8. Have you ever experienced any strong fears? For example, of heights, insects, animals, dirt, attending social events, being in a crowd, being alone, being in places where it may be hard to escape or get help? *

Yes
No

9. Have you ever given in to an aggressive urge or impulse, on more than one occasion, that resulted in serious harm to others or led to the destruction of property? *

Yes
No

10. Have you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior? *

Yes
No

11. Have you ever had a period of time when you were so full of energy and your ideas came very rapidly when you talked nearly non-stop, when you moved quickly from one activity to another, when you needed little sleep, and believed you could do almost anything? *

Yes
No

(Do not consider times when you were intoxicated on drugs or alcohol)

12. Have you ever had spells or attacks when you suddenly felt anxious, frightened, uneasy to the extent that you began sweating, your heart begin to beat rapidly, you were shaking or trembling, your stomach was upset, you felt dizzy or unsteady, as if you would faint? *

Yes
No

13. Was there a period in your life when you spent a lot of time thinking and worrying about gaining weight, becoming fat, or controlling your eating? For example, by repeatedly dieting or fasting, engaging in much exercise to compensate for binge eating, taking enemas, or forcing yourself to throw up? *

Yes
No

14. Have you ever been bothered by recurrent thoughts, impulses, or images that were unwanted, distasteful, inappropriate, intrusive, or distressing? *

Yes
No

15. Have you ever done something repeatedly without being able to resist doing it, like washing or cleaning excessively, counting or checking things over and over, or repeating, collecting, or arranging things or other superstitious rituals? *

Yes
No

Psychiatric

How many times have you been treated for any psychological or emotional problems?

In hospital: *

As an Outpatient. or Priv. Patient: *

Do you receive a pension for a psychiatric disability? *

Yes
No

Have you had a significant period (that was not a direct result of drug/alcohol use), in which you have:

Experienced serious depression:

Past 30 days: *

Yes
No

In life time: *

Yes
No

Experienced serious anxiety or tension:

Past 30 days: *

Yes
No

In life time: *

Yes
No

Experienced hallucinations:

Past 30 days: (copy) *

Yes
No

In life time: (copy) *

Yes
No

Experienced trouble understanding, concentrating, or remembering:

Past 30 days: (copy) (copy) *

Yes
No

In life time: (copy) (copy) *

Yes
No

Experienced trouble controlling violent behavior:

Past 30 days: (copy) (copy) (copy) *

Yes
No

In life time: (copy) (copy) (copy) *

Yes
No

Experienced serious thoughts of suicide:

Past 30 days: (copy) (copy) (copy) (copy) *

Yes
No

In life time: (copy) (copy) (copy) (copy) *

Yes
No

Attempted suicide:

Past 30 days: (copy) (copy) (copy) (copy) (copy) *

Yes
No

In life time: (copy) (copy) (copy) (copy) (copy) *

Yes
No

Been prescribed medication for any psychological emotional problem:

Past 30 days: (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

In life time: (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

How many days in the past 30 days have you experienced these psychological or emotional problems? *

PAGE 11

COMMUNITY COUNSELING CENTER

Client Information Sheet

Name *

First

Last

Date *

Drug Use: Check all drugs you have used:

Lifetime Use (years) *

Age at First Use *

Lifetime Use (years) *

Age at First Use *

Lifetime Use (years) *

Age at First Use *

Lifetime Use (years) *

Age at First Use *

Lifetime Use (years) *

Age at First Use *

Lifetime Use (years) *

Age at First Use *

Lifetime Use (years) *

Age at First Use *

Lifetime Use (years) *

Age at First Use *

Lifetime Use *

Age at First Use *

Lifetime Use *

Age at First Use *

Lifetime Use *

Age at First Use *

Lifetime Use *

Age at First Use *

Lifetime Use *

Age at First Use *

Describe first use of alcohol or other drugs: *

Preferred drug or alcoholic beverage: *

Quantity per occasion: *

Frequency: *

First awareness of a problem? *

(Describe age and situation. Write none if none.)

Describe changes in drinking or drug use pattern lately: *

(Describe situation. Write none if none.)

Have you noticed a need for increased amounts to achieve intoxication? *

Yes
No

Can you avoid withdrawals by substituting another drug? *

Yes
No

Explain: *

Have you ever tried to cut down your use? *

Yes
No

Have you experienced periods of being completely alcohol and drug free? *

Yes
No

Did you use a support system such as AA/NA/CA? *

Yes
No

Have you ever been to anyone for help w/your drinking/drug use? *

Yes
No

Have you ever been to an alcohol/drug treatment center? *

Yes
No

How many times in your life have you been treated for:

Alcohol Abuse: *

How many times have you had alcohol d.t.’s? *

Drug Abuse:

How many of these were detox only?

Alcohol: *

Drugs: *

How much money did you spend in the past 30 days on:

Alcohol: *

Drugs: *

In the last 30 days, have you experienced:

Alcohol problems: *

Yes
No

Drug problems: *

Yes
No

How many days have you been treated in an outpatient setting for alcohol or drugs in the past 30 days?(Include NA, AA): *

How troubled or bothered have you been in the past 30 days by the following:

How important to you now is treatment for the following:

Social Relationships

Have your friendships changed over time? *

Yes
No

Do a majority of your friends drink and/or use drugs? *

Yes
No

Do you have a friend(s) to whom you confide your feelings and problems? *

Yes
No

Family of Origin

Describe your relationship with your parents: *

Give the ages and sex of sibling(s) (brothers/sisters): *

(Place a comma between each person. Write none if none)

Describe the atmosphere at home when you were growing up: *

Did your parents show affection? *

Yes
No

Describe your parents attitude towards drinking (Teetotalers, social drinkers, heavy drinkers): *

Did anyone in your family of origin have a serious drinking problem or drug problem? *

Yes
No

Do you live with anyone who uses non-prescribed drugs? *

Yes
No

With whom do you spend most of your free time? *

Family
Friends
Alone

Are you satisfied spending your free time this way? *

Yes
No
Indifferent

Have you had significant periods in which you have experienced serious problems getting along with the following:

Mother:

Past 30 days: *

Yes
No

Past 6 Months: *

Yes
No

In Lifetime: *

Yes
No

Father:

Past 30 days: *

Yes
No

Past 6 Months: *

Yes
No

In Lifetime: *

Yes
No

Brother/Sister:

Past 30 days: *

Yes
No

Past 6 Months: *

Yes
No

In Lifetime: *

Yes
No

Sexual Partner/Spouse:

Past 30 days: *

Yes
No

Past 6 Months: *

Yes
No

In Lifetime: *

Yes
No

Children:

Past 30 days: (copy) *

Yes
No

Past 6 Months: (copy) *

Yes
No

In Lifetime: (copy) *

Yes
No

Other Significant Family Member:

Past 30 days: (copy) (copy) *

Yes
No

Past 6 Months: (copy) (copy) *

Yes
No

In Lifetime: (copy) (copy) *

Yes
No

Other Member (name):

Past 30 days: (copy) (copy) (copy) *

Yes
No

Past 6 Months: (copy) (copy) (copy) *

Yes
No

In Lifetime: (copy) (copy) (copy) *

Yes
No

Name

First

Last

Close Friends:

Past 30 days: (copy) (copy) (copy) (copy) (copy) *

Yes
No

Past 6 Months: (copy) (copy) (copy) (copy) *

Yes
No

In Lifetime: (copy) (copy) (copy) (copy) *

Yes
No

Neighbors:

Past 30 days: (copy) (copy) (copy) (copy) *

Yes
No

Past 6 Months: (copy) (copy) (copy) (copy) (copy) *

Yes
No

In Lifetime: (copy) (copy) (copy) (copy) (copy) *

Yes
No

Co-Workers:

Past 30 days: (copy) (copy) (copy) (copy) (copy) *

Yes
No

Past 6 Months: (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

In Lifetime: (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

Did any of these people abuse you?

Physically (cause you physical harm):

Past 30 days: (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

Past 6 Months: (copy) (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

In Lifetime: (copy) (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

Sexually (force sexual advances or sexual acts):

Past 30 days: (copy) (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

Past 6 Months: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

In Lifetime: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) *

Yes
No

How many days in the past 30 days have you had serious conflicts?

With your family: *

(# of days)

With other people (not including family): *

(# of days)

Religious/Culture:

Describe Your Religious Training: *

(if none, type none)

Present Church attendance: *

(if none, type none)

Describe your spiritual beliefs: *

(if none, type none)

Activities Assessment:

Has your involvement in leisure time activities changed over time? *

Yes
No

Interest in new activities changed over time? *

Yes
No

Legal History:

Was this visit prompted or suggested by the criminal justice system? *

Yes
No

(Judge, Probation/ Parole Officer, etc.)

Are you on probation or parole? *

Yes
No

How many times in your life have you been arrested and charged with the following (type number or use arrows):

Shoplifting, Vandalism: *

Weapons Offense: *

Arson: *

Contempt of Court: *

Parole/Probation Violation(s): *

Burglary, Larceny, Breaking and Entering: *

Rape: *

Restraining Order: *

Drug charges: *

Robbery: *

Homicide, manslaughter: *

Forgery: *

Assault: *

Prostitution: *

Other: *

How many of these charges resulted in conviction? *

How many times in your life have you been charged with the following (type number or use arrows):

Disorderly conduct: *

Driving while intoxicated: *

Major driving violations: *

(reckless driving, speeding, no license, etc.)

How many total months have you been incarcerated in your life? *

Which arrests were drinking/drug related? *

(place a comma between items)

Explain: *

Are you presently awaiting charges, trial, or sentencing? *

Yes
No

How many days in the past 30 were you detained or incarcerated? *

(# of days)

How many days in the past 30 have you engaged in illegal activities for profit? *

(# of days)

In completing this questionnaire, you may have described some past events which may have affected your attitude. List those problem areas you believe you need to work on during the next weeks as means of re-establishing and reinforcing your comfort with a drug free life.

Identified problems causing reduced function: *

Goals: *

PAGE 12

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION:

CRIMINAL JUSTICE SYSTEM REFERRAL

I, *

First

Last

(Name of defendant)

Authorize:

Initial: *

(initial whichever parties apply)

First, Last *

First

Last

(Name or general designation of program making disclosure)

Initial: *

First, Last *

First

Last

Initial: *

First, Last *

First

Last

Initial: *

Single Line Text *

(Name of the appropriate court)

Initial: *

Single Line Text *

(Name of prosecuting attorney)

Initial: (copy) *

Single Line Text (copy) *

(Name of criminal defense attorney)

To communicate with and disclose to one another the following information (nature and amount of the information as limited as possible):

Checkboxes

My diagnosis, urinalysis results, information about my attendance or lack of attendance at Treatment sessions, my cooperation with the treatment program, prognosis,

Checkboxes (copy)

and

Paragraph Text

The purpose of the disclosure is to inform the person(s) listed above my attendance and progress in treatment.

I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”), 45 C.F.R. Pts. 160 & 164. I also understand that I may revoke this consent at any time except to the extend that action has been taken in reliance on it, and that in any even this consent expires automatically as follows:

[Specify the date, event or condition upon which this consent expires. This could be one of the following:]

Checkboxes (copy)

there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment,

Checkboxes (copy) (copy)

or

Paragraph Text (copy)

(Specify other time when consent can be revoked and/or expires)

understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I have been provided a copy of this form. *

(dated)

Signature of Patient: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Please type NA in signature field if client is not signing.)

(dated)

Signature of person signing, if not the patient: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Please type NA in signature field if client is signing.)

Describe authority to sign on behalf of patient: *

(complete only if patient is NOT signing. Write N/A if not completing.)

PAGE 13

CONSENT FOR THE RELEASE OF
CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION

I, *

First

Last

(Name of patient)

authorize *

First

Last

to disclose to *

(Name of person or organization to which receipt/disclosure is to be made)

the following information: *

(Nature of the information, as limited as possible)

The purpose of the disclosure authorized is to: *

(Purpose of disclosure, as specific as possible)

I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPPA), 45 C.F.R. Pts. 160 &164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:

Single Line Text *

(Specification of the date, event, or condition upon which this consent expires)

(dated)

Signature of Participant: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Please write NA in signature field if Participant IS NOT signing.)

Signature of person signing, if NOT the Participant: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Please write NA in signature field if Participant IS signing.)

CARSON JUSTICE COURT
EVALUATION REVIEW FORM

I have read, reviewed and understand the recommendations contained in my evaluation.

Defendant Name: *

First

Last

Signature of Defendent: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Evaluator

(sign printed form)

PAGE 14

NRS 629.051 – Health care records: Retention; disclosure to patients concerning destruction of records; exceptions; regulations.

1 Except as otherwise provided in this section and in regulations adopted by the State Board of Health pursuant to NRS 652.135 with regard to the records of a medical laboratory and unless a longer period is provided by federal law, each provider of health care shall retain the health care records of his or her patients as part of his or her regularly maintained records for 5 years after their receipt or production. Health care records may be retained in written form, or by microfilm or any other recognized form of size reduction, including, without limitation, microfiche, computer disc, magnetic tape and optical disc, which does not adversely affect their use for the purposes of NRS 629.061. Health care records may be created, authenticated and stored in a computer system which limits access to those records.

2. A provider of health care shall post, in a conspicuous place in each location at which the provider of health care performs health care services, a sign which discloses to patients that their health care records may be destroyed after the period set forth in subsection 1.

3. When a provider of health care performs health care services for a patient for the first time, the provider of health care shall deliver to the patient a written statement which discloses to the patient that the health care records of the patient may be destroyed after the period set forth in subsection 1.

4. If a provider of health care fails to deliver the written statement to the patient pursuant to subsection 3, the provider of health care shall deliver to the patient the written statement described in subsection 3 when the provider of health care next performs health care services for the patient.

5. In addition to delivering a written statement pursuant to subsection 3 or 4, a provider of health care may deliver such a written statement to a patient at any other time.

6. A written statement delivered to a patient pursuant to this section may be included with other written information delivered to the patient by a provider of health care.

7. A provider of health care shall not destroy the health care records of a person who is less than 23 years of age on the date of the proposed destruction of the records. The health care records of a person who has attained the age of 23 years may be destroyed in accordance with this section for those records which have been retained for at least 5 years or for any longer period provided by federal law.

8. The provisions of this section do not apply to a pharmacist.

9. The State Board of Health shall adopt:
a. Regulations prescribing the form, size, contents and placement of the signs and written statements required pursuant to this section; and
b. Any other regulations necessary to carry out the provisions of this section.

(Added to NRS by 1977, 1313; A 1993, 916; 1997,1123; 2009,2549)

SUBSTANCE ABUSE PREVENTION & TREATMENT SERVICES
ACKNOWLEDGE OF CONSUMER INFORMATION

I, *

First

Last

acknowledge receiving a copy of the MEDICAL RECORD RETENTION POLICY. In accordance with the provisions of SB!& of the 209 Session, health care records of a consumer who is less than 23 years of age may not be destroyed. Records may be destroyed if retained for at least 6 years after the person has reached 23 years of age.

Consumer Signature: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Please type NA in signature field if Consumer IS NOT signing.)

Date: *

(date of signature)

Parent or Legal Guardian Signature: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document. (Please type NA in signature field if Consumer IS signing.)

Date: *

(date of signatures)

Office Staff Signature

Use your mouse or finger to sign if signing electronically. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date:

(date of signature)

PAGE 15

CCCofCC RULES

Name *

First

Last

Be on time. If you are late, you will not be permitted into group. THIS INCLUDES RESTROOM.

# of twelve step meetings per week you must attend and bring proof of attendance to counseling groups. Must complete all homework assignments. *

You must attend an individual session with a counselor once a month to be scheduled by the 25th of the previous month. For example, in order to have an appointment for November, you will have to have it scheduled by the 25th of October.

Clean after yourself after each group session. The room is expected to be left clean after each use.

No food, gum, or drinks are allowed in the building with the exception of water in a clear plastic bottle. If you are observed eating in the building you will get a missed group and be asked to stay.

Please do not leave trash anywhere in the building, outside of the building or on our neighbor’s property, use trash cans and trash dumpster.

Dress appropriately every time you enter the building; this includes groups, individual sessions or if you are here to test.Shirts must have sleeves. No hats, sunglasses, tank tops, bikini/bathing suits, pajamas, slippers, short shorts, mini-skirts, cleavage revealing outfits or buttocks revealing outfits. No clothing with prejudicial or alcohol/drug related material, foul language, or rude/crude statements or pictures.

Do not cross talk. Raise your hand to speak.

No cell phones in the building at any time; this includes group, individual appointments or if you are here to test. Leave them in vehicles. If your cell phone rings or vibrates you will get a missed group and be asked to stay.

No tobacco products in the building and no smoking on the property, this includes vapes, e-cigarettes and tobacco chew. You may smoke in the back alley before and after your scheduled group, behind CCC building as you are not allowed to leave the building during group or break; you will see a cigarette receptacle.

No loitering on or around our neighbors property i.e. bank parking lot, in front of residents homes or in front of CCC building. If you are waiting for group please wait in the back alley of the CCC building.

Use the bathroom before group as it is disruptive to exit during the group and you may not be late to group. You are expected to stay in the room during the entire group.

Park your vehicle in assigned client parking, such as the parking lot behind CCC building and nearby public street parking. Do not park in front of neighbors parking or on personal property i.e. home driveways and other business parking lots or your vehicle may be towed.

Drive at the posted MPH, this is also a residential area and there are children on the street.

Drive to CCC building quietly. TURN OFF YOUR RADIO! Please note that there are sessions occurring throughout the day and having a vehicle with loud music is disruptive both to this agency and to our neighbors.

Be respectful of peers, CCC staff, property, and neighbors of the property. This includes sitting appropriately in chairs DO NOT SLOUCH ON CHAIR OR SLEEP IN GROUP and not destroying chairs i.e. don’t pick the chairs or write on them. Do not take or remove any items from the agency.

Be attentive to those speaking (no sleeping or doodling).

No profanity, violence, or intimidation.

Pay on your bill and/or communicate with the office on payment arrangements.

Submit to random alcohol and/or drug testing.

Confidentiality: who you see here and what is said here will not be repeated outside of treatment, including individuals in other groups, or private sessions. Please be careful to remember that people may not wish to be addressed/acknowledged by you outside of treatment as it would break their confidentiality. Breaking confidentiality compromises that person’s treatment as he/she can no longer trust in the group and receive proper therapy as a result.

You may be discharged or asked to meet with your individual counselor if you have two unexcused absences within the entire treatment episode. These absences include groups and individual sessions. Lack of payment is not an excused absence.

If you are going to be missing group, please notify your counselor as to why ahead of time. If you want to be excused from group for being sick, you must either have a complete doctor’s note or hospital discharge form validating the group time missed or you must show up to group and be sent home sick by your counselor.

Do not use any alcohol or drugs including prescription narcotics, sedatives, hypnotics, etc. while in treatment. Inform staff of all medications you are taking and get approval for any over the counter medications you intend to take. This is an abstinence only treatment program and you may be inappropriate for treatment here if you are on any mood-altering substance even with a doctor’s prescription.

If you are prescribed medication obtain approval from your Counselor PRIOR to taking it. You may only take what is on the approved medication list.

The violation of any of these rules will result in a missed group. Continued violation of these rules may lead to an unsuccessful discharge from treatment with a letter to your source of referral.

Signature: *

Use your mouse or finger to sign. By entering your legal name into this document, you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.

Date: *

(date of signature)

PAGE 16

Aftercare/Discharge Plan

To be completed at Admission:

Name of next level of care provider: *

Phone Number: *

Contact Person: *

Specfic Service: *

Supports needed, including referral to CMH (687-4195):

(complete as needed)

Referrals for Vocational:

(complete as needed)

Educational:

(complete as needed)

Specialized services like interpreter:

(complete as needed)

Future Goals with time frames: *

Client Acknowledgment: *

(type name)

Counselor:

Community Counseling Center

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

1. Our pledge regarding Protected Health Information (PHI):

2. Our Legal Duty LEGAL DUTY

Law Requires Us to:

We Have the Right to:

Notice of Change to Privacy Practices:

3. Use and Disclosure of Your Protected Health Information

FOR TREATMENT:

FOR PAYMENT:

FOR HEALTH CARE OPERATIONS:

ADDITIONAL USES AND DISCLOSURES:

4. Your Individual Rights INDIVIDUAL RIGHTS

PAGE 01

COMMUNITY COUNSELING CENTER INTAKE FORM

How much money did you receive from the following sources in the past 30 days?

PAGE 2

COMMUNITY COUNSELING CENTER CONSENT TO TREATMENT

CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

PAGE 3

Community Counseling Center Client Complaint Procedure

PAGE 4

Substance Abuse Prevention and Treatment Agency Sliding Fee Scale Policy Statement July 1, 2010

SLIDING FEE SCALE WORKSHEET/AGREEMENT

SUBSTANCE ABUSE PREVENTION AND TREATMENT AGENCY

PAGE 5

POLICY-HOLDER’S INSURANCE FORM

AUTHORIZATION TO PAY PROVIDER

Financial Terms and Co-pays:

PAGE 6

PAGE 7

CONDITIONS

PAGE 8

MEDICAL QUESTIONNAIRE

PAGE 9

PAGE 10

Psychiatric

PAGE 11

COMMUNITY COUNSELING CENTER

PAGE 12

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION:

CRIMINAL JUSTICE SYSTEM REFERRAL

PAGE 13

CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION

CARSON JUSTICE COURT EVALUATION REVIEW FORM

PAGE 14

SUBSTANCE ABUSE PREVENTION & TREATMENT SERVICES ACKNOWLEDGE OF CONSUMER INFORMATION

PAGE 15

PAGE 16

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Substance Abuse Prevention and Treatment Agency
Sliding Fee Scale
Policy Statement
July 1, 2010

CONSENT FOR THE RELEASE OF
CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION

CARSON JUSTICE COURT
EVALUATION REVIEW FORM

SUBSTANCE ABUSE PREVENTION & TREATMENT SERVICES
ACKNOWLEDGE OF CONSUMER INFORMATION