Intake Paperwork Form.

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Disclaimer

I acknowledge and understand that program admission is based on clinical determination of program appropriateness. Completion of intake documentation does not guarantee program acceptance or insurance approval/authorization. My signature below represents my understanding of this disclaimer.

Signature of Patient: *

Date: *

Patient Name *

First

Last

Consent to Treatment

By signing below, I hereby consent to and authorize the administration and performance of all treatments as may be deemed necessary or advisable by a duly authorized and qualified health care professional. In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, therapy, or medication recommended or deemed medically necessary by my health care professional. I fully understand that this consent is given in advance of any specific treatment. I intend this consent to be continuing in nature even after treatment has been recommended. The consent will remain in full force and effect until revoked in writing.

Consent to Release Medical Information for Treatment and Payment Purposes.

By signing below, I hereby authorize Williamsville Wellness to release medical information to any of my physicians or insurance companies that may be pertinent to my care. I hereby authorize payment directly to Williamsville Wellness of benefits otherwise payable to me. I hereby authorize the release of my medical records to third party insurers or other authorized persons to whom disclosure is necessary to establish or collect a fee for the services provided. I understand that I am financially responsible for charges not covered by this authorization.

Acknowledgement of the Confidentiality and Privacy Rules Relating to Patient Information

State and federal laws require that we keep your treatment records private, unless otherwise required by law. Therefore, the contents of an intake assessment or counseling sessions are considered to be confidential. Both verbal information and written records about a patient cannot be shared with another party without the consent of the patient or the patient’s legal guardian, except in limited circumstances. It is our policy to not release any information about a patient without a signed release of information, unless required by law. In certain circumstances, noted below, we are permitted to disclose certain information about you without your consent:

Duty to Warn and Protect

A mental health service professional has a duty to take precautions to protect third parties from violent behavior or other serious harm when a patient has orally, in writing, or via sign language, communicated to the professional a specific and immediate threat to cause serious bodily injury or death to an identified or readily identifiable person, if the professional reasonably believes that the patient has the intent and ability to carry out that threat immediately or imminently. To discharge this duty, the professional may warn the potential victim and may notify law enforcement.

Abuse of Children or Vulnerable Adults If a health care professional has reason to suspect that a child or aged or incapacitated adult has been or is being abused, neglected, or exploited, the professional must report the matter immediately to the local social services department. Newborn infants who have been medically diagnosed for exposure to non-prescription, controlled substances during pregnancy are considered to be at risk of abuse or neglect. A health care professional must report these children to the appropriate social services department. Prenatal Exposure to Controlled Substances Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

Professional Misconduct Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns. Court Orders and Proceedings Health care professionals are required to release records of patients when a subpoena and an authorizing court order based on good cause shown has been entered. In addition, a health care professional may disclose information relevant to an individual’s mental condition in certain court proceedings. Emergencies and Research Activities Health care professionals may disclose patient identifying information to medical personnel who have a need for such information in connection with a medical emergency. Professionals also may disclose patient identifying information for the purpose of conducting scientific research in certain circumstances. In the Event of a Patient’s Death Health care professionals may release a deceased patient’s information to a duly authorized executor, administrator, or other such authorized individual when such information is relevant to the personal representation. Consultations Information about patients may be disclosed in consultations with other professionals in order to provide the best treatment possible. In such cases the name of the patient, or any identifying information, is not disclosed. Clinical information about the patient is discussed. Psychotherapy Notes We may not disclose any psychotherapy notes without your prior written authorization, except in limited circumstances. Other Releases as Permitted by Law In addition to the instances set forth in this document, health care professionals may disclose information without patient consent as otherwise may be permitted by applicable law, including, but not limited to, Va. Code Ann. § 32.1- 127.1:03, 12 Va. Admin. Code 35-115-80(B), and 42 C.F.R. Part 2.

I have read the Consent to Treatment form in its entirety and any questions I had about its content have been fully answered to my satisfaction. I certify that I fully understand the contents of this form, and I consent fully and voluntarily to its contents.

Signature of Patient: *

Printed Name: *

First

Last

Williamsville Wellness Outpatient Policies

This document contains Williamsville Wellness’ Outpatient policies. Please read the document carefully. By signing below, you acknowledge that you have read, understand, and consent to these policies and the requirements described in this form. Williamsville Wellness reserves the right to make changes to these policies at its discretion.

General Information

The Williamsville Wellness offers two programs, Partial Hospitalization [PHP] and Intensive Outpatient [IOP]. The IOP/PHP is a volunteer program which serves adults with substance use disorder and co-occurring mental health concerns. The IOP/PHP is staffed by doctoral and master’s level licensed professional counselors, certified substance abuse counselors, and qualified mental health professionals. In addition to the individual sessions, the IOP/PHP offers group sessions that take place under the direction of experienced therapists and facilitators. These sessions are focused on addiction education, self-awareness, coping and recovery skills, and interpersonal communication and expression.

The PHP program is a four (4) week program which consists of group therapy via 20 specialized modules and individual therapy. The individual in treatment will meet one-on-one with a therapist at least 5 times per week.

The IOP program is a six (6) week program which consists of group therapy via 24 specialized modules and individualized therapy. The individual in treatment will meet one-on-one with a therapist at least 1 per week.

Admission criteria for the program are that the individual recognizes the need for change with regard to substance use (falls anywhere between precontemplation to action stages of change); the individual is medically stable, the individual has the cognitive capacity to follow program content and group sessions, and the individual agrees to follow program policies and guidelines. Admission and discharge criteria are in compliance with 12VAC35-105-1360. Exclusionary criteria for the program are individuals who are at imminent risk of harm to themselves or
others, and individuals who are actively psychotic or delusional.

Program Expectations and Rules

1. Funding

● Payment for each individual in the Intensive Outpatient Program comes from either self-pay, family support, health insurance benefits, or a combination thereof.

2. Outpatient Schedule and Attendance

● IOP

○ The IOP is a 6 week program which takes place four days per week (Monday-Thursday).
Daytime IOP is from 12:30 to 3:30 and evening IOP is from 6:00 PM to 9:00 PM each day.
Individuals are successfully discharged from the program after they complete the 6-week
program (24 sessions total).

● PHP

○ PHP is a 4 week program taking place five days a week (Monday-Thursday 12:30-5:30 and
Friday 12-5). Individuals are successfully discharged from the program after they complete
the 4-week program (20 sessions total).

❏ One (1) or more unexcused absences will result in program dismissal and non-completion unless otherwise specified.

❏ Please arrive on time. You will be marked absent if you arrive more than 20 minutes late. You will be marked absent if you leave more than 15 minutes early [unexcused].

❏ Absences, lateness, or early dismissal from sessions are permitted for illness, health reasons, family emergencies, vacations and/or with the Clinical Director’s approval. In the case of needing to miss a session, you must contact Jay Bach prior to the start of the IOP/PHP at 804-559-9959 ext. 114. Excused absences can be made up.

❏ A requirement and expectation is that every group member is in the IOP/PHP group room,
seated, and ready to begin at the start of group. A pattern of late arrivals may result in program
dismissal and non-completion.

○ be issued within approximately one week of the time of admission into the program.

3. Drug Screening/Breathalyzers

● Individuals enrolled in the Williamsville Wellness Outpatient will be administered random drug screens and/or random breathalyzers at least once per week; and may be administered random drug screens and/or random breathalyzers at any time. If it is suspected that you have arrived to group under the influence of drugs or alcohol, we reserve the right to:

○ Refuse your participation in programming for the evening or for a period of time determined by us;

○ Dismiss you from the group;

○ Arrange for an alternative means for you to return home;

○ Report you to the police if you drive under the influence versus return to your home by the means proposed by us.

4. Confidentiality

● Participants in treatment at Williamsville Wellness agree not to disclose to anyone outside of the group any information that is disclosed, observed, or otherwise relates to a session or group member, including, but not limited to, information that could be used to identify another group member. This includes, but is not limited to, names, physical descriptions, biological information, and specifics to the content of interactions with other group members.

5. Interpersonal Conduct

● Patients are expected to be respectful and to use respectful language when interacting with all staff and other patients. Language including but not limited to off-color remarks or jokes, racial slurs, gender, age, sexuality, or ethnicity will not be tolerated, and dismissal from the program may take place.

● Refrain from engaging in romantic, sexual, or sexually provocative behavior with other patients or staff.

● Do not lend money to others.

● Do not engage in business, trade or barter with another person (no buying or selling of personal items or personal services).

● Please be courteous to others

● Cell phones may only be used during breaks, and may never be used in the group room.

6. Smoking Policy

● Smoking is allowed outside the building in the designated smoking areas only. Smokeless tobacco, ecigarettes, vapors, etc. are also to be used outside in these designated areas. Please use proper disposal cans.

7. Rules

● A violation of any of the following rules will result in penalties; and may result in dismissal from treatment. One violation of one or more of the following rules after a warning will result in dismissal.

○ Use of cell phones, tablets, electronic devices, and other communication or recording devices in the group room. Texting, talking, emailing, accessing of the Internet, and all other uses of any
communication or recording devices are strictly prohibited in the group room, including during
breaks. During breaks exclusively, cell phones and other devices may be used, but only outside the group room.

○ Excessive late arrivals will not be allowed. It is expected that every group member arrives on time to all group sessions.

○ Excessive absences will not be allowed. More than four unexcused absences will result in dismissal from the treatment program.

○ No revealing attire.

Dress Code:

● When attending our program, please keep in mind that Williamsville has a patient dress code. Please review what is and is not permitted at Williamsville Wellness.

● Patient dress at Williamsville Wellness is casual. All clothing must be acceptable for a coed facility. Shoes are required at all times.

● Dress must be appropriate, i.e., clothing that depicts alcohol, drugs, sex, violence, gambling, inappropriate words/slogans or any clothing deemed inappropriate by staff is not allowed.

8. Zero Tolerance Rules

● Violation of the following rules will not be tolerated.

○ Engaging in sexual, gambling, drinking, drug use activities at the facility.

○ Causing physical harm to another person.

○ Threatening another person.

○ Stealing equipment from the outpatient facility.

***Patients who engage in any of these will be asked to leave the premises immediately and their treatment will be
terminated, additional legal actions may be taken in some cases.

Acknowledgment and Consent

By initialing here and signing below, you hereby consent to the administration of drug screens and/or breathalyzers as described in this form. This includes consent to the administration of random drug screens and/or random breathalyzers at any time, and the rights that we reserve if we suspect that you have arrived to group under the influence of drugs or alcohol.

Please Initials *

By signing below, I indicate that I have carefully read and understand the program policies, expectations and rules, and that I agree to the terms and conditions in this form. Without limiting the generality of the foregoing, I specifically consent to the use of video recording devices in the group sessions and to the use of such recordings by Williamsville Wellness for purposes described in this form. I also consent to the administration of drug screens and breathalyzers as described in this form. I have asked and answered any questions I have concerning these policies and am aware that signing this agreement is required for my admission to the Williamsville Wellness Outpatient treatment program. I am also aware that my refusal to sign this agreement will exclude me from participating in the group.

Printed Name: *

First

Last

Signature: *

Date of birth *

Notice of Privacy Practices

This notice describes how medical and mental health information about you may be used and disclosedand how you can get access to this information. Please review it carefully.

During the process of providing services to you, Williamsville Wellness, LLC (WW) will obtain, record, and use addiction, mental and medical information about you that is protected health information (PHI). Ordinarily that information is confidential and will not be used or disclosed, except as described below. This notice is required by a federal law known as HIPAA and describes how we may use and disclose your PHI in accordance with the law. WW is required to abide by the terms of this notice, or any amended notice that may follow. This notice is effective September 23, 2013.

Our Obligations. Williamsville Wellness (WW) is required by State and Federal law to maintain the privacy of protected health information (PHI). WW is required by law to provide clients with notice of our legal duties and privacy practices with respect to PHI. There are circumstances where other state and federal laws are more stringent than HIPAA, and in such cases, we will follow those laws with respect to the limitation on uses and disclosures of your information. We will notify you as required by law in case of a breach of your unsecured protected health information.

Uses and Disclosures. WW may use and disclose PHI without your consent in the following ways:

Treatment. We will use and disclose your health information to provide, coordinate, or manage health care (including mental health care) and related services. For example, staff involved with your care may use your information to plan your course of treatment and consult with other staff to ensure the most appropriate methods are being used to assist you.

Payment. We will use your health information for payment purposes. For example, we will use your information to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company for services provided. The information provided to insurers and other third party payers may include information that identifies you, as well as your diagnosis, type of service, provider name/identifier, and other information about your condition and treatment.

Health Care Operations. We may use and disclose your health information to run our business, improve your care, and generally support the business activities of WW. For example, we will use health information about you to manage your treatment and services.

In addition, we are allowed or required to share your information in other ways, often in ways that contribute to the public good. For example, we are allowed or required to share your information for the following purposes:

Public Health and Safety. We can share health information about you for certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.

Research. We may use your information to conduct research, and we may disclose your information to researchers as authorized by law.

Compliance with Law. We will share information about you if state or federal law requires such
disclosure, including with the Department of Health and Human Services.

Workers’ Compensation and Other Lawful Requests. We can use or disclose information about you for workers’ compensation claims; for law enforcement purposes; with health oversight agencies for activities authorized by law; or for special government functions such as military, national security, and secret service activities.

Lawsuits and Legal Actions. We can share information about you in response to a valid subpoena and court order.

Authorizations. WW may not disclose PHI in any way other than described in this notice without written authorization. Examples of disclosures or uses requiring authorization include certain disclosures of psychotherapy notes, marketing communications, and disclosures that constitute a sale of your information. You may revoke authorizations at any time in writing except to the extent WW has taken action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, the insurer may contest a claim under the policies or the policy itself.

Right to Request Restrictions. You may ask us not to use or share certain health information for treatment, payment, or our operations, or you may ask us not to share information with family members or friends involved in your care or for notification purposes. You must provide us with the specific restriction and to whom you want the restriction to apply. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. If we agree to a requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with us. You may request a restriction by designating that restriction in writing.

Your Privacy Rights. You have rights with respect to your PHI. To exercise any of these rights, or for any questions or further information about this Notice, contact WW Business Manager at 804-559-9959 ext.100 or 104. Access to your information. You have the right to inspect or obtain a copy of the protected health information we maintain about you. There are some limitations to this right, which will be explained to you at the time of the request, if applicable.

Amendment of Your Record. You have the right to request that WW amend (correct) your PHI. We are not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be explained to you at the time of your request, if relevant, along with the appeal process available to you.

Accounting of Disclosures. You can ask for a list (an “accounting”) of the disclosures we have made of your health information for up to six years prior to the date of your request, who we shared it with, and why. We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make, to family and friends involved in your care or to notify them, or to a facility directory). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Confidential Communications. You have the right to request that we communicate with you by
alternative means. For example, if you do not want us to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be explained to you at the time of the request process, if applicable.

Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice upon request.

Complaints If you believe WW has violated your privacy rights, you have the right to file a complaint with WW. To file your complaint, contact the Business Manager at 804-559-9959 ext. 100 or 104. You may also complain to the United States Secretary of Health and Human Services. WW will not retaliate against you for filing a complaint.

Changes to this Notice. WW reserves the right to change the terms of this notice and to make new provisions effective for all PHI that we maintain. When the notice is revised, the revised notice will be posted in WW facilities. You also can obtain a copy of the revised notice upon request.

Notice of Privacy Practices Acknowledgment Form.

I acknowledge that I have received the Notice of Privacy Practices from Williamsville Wellness and that I have been provided an opportunity to review it.

I understand that:

● I have certain rights to privacy regarding my protected health information.
● Williamsville Wellness can and will use my health information for purposes of my treatment,
payment, and health care operations.
● The notice explains in more detail how Williamsville Wellness may use and share my protected
health information for other purposes.
● Williamsville Wellness has the right to change the notice from time to time, and I can obtain a
current copy of the notice by contacting the person listed in the notice.

Printed Name: *

First

Last

Signature: *

Date of birth *

Patient Rights and Responsibilities

It is the policy of Williamsville Wellness, LLC to ensure and protect patient rights at all times. Upon admission, each patient will be given a copy of his/her rights as stated below. Each patient has the right to a complete copy of the regulations governing patient rights set forth at 12 Va. Admin. Code 35-115-10 et seq. upon request. It is the responsibility of the staff to ensure that each patient has a full understanding of these rights.

You have the right to…

Respect and Dignity- Williamsville Wellness fully supports an individual’s right to exercise his/her legal, civil, and human rights, including constitutional rights, statutory rights. Each individual has the right to be protected, respected and supported in exercising these rights. Each individual has the right to considerate, respectful care at all times and under all circumstances with recognition of personal dignity.

Protection from Harm – Each individual has the right to be free from abuse, neglect, or exploitation. In the event of any signs of abuse, neglect, or exploitation, the Clinical Director will immediately notify a human rights advocate and the individual’s authorized representative.

Access to Services- Each individual has a right to receive prompt services that are provided consistent with sound therapeutic practices and that are person-centered and respond to the individual’s needs and preferences. In addition, each individual has a right to impartial access to services that are available or clinically indicated regardless of race, color, religion, gender, sexual orientation, ethnicity, age, or disability.

Participation and Decision Making and Consent- Each individual has the right to participate meaningfully in decisions regarding all aspects of services affecting him/her. This includes the right to consent or not consent to receive or participate in services.

Confidentiality- Each individual is entitled to have all identifying information that Williamsville Wellness maintains or knows about him/her to remain confidential. Each individual has the right to give his/her authorization before Williamsville Wellness shares information about him/her except when another state law or regulation specifically require or permit us to disclose certain specific information.

Restrictions on Freedoms of Everyday Life- Williamsville Wellness will ensure that every patient shall enjoy the freedoms of everyday life that are consistent with his/her need for treatment, for his/her protection, and protection of others, and that do not interfere with his/her treatment or the treatment of others. Each individual has a right to receive services in a setting and under conditions that are the least restrictive of the individual’s freedom and to not be subjected to unnecessary physician restraint or seclusion.

Access to Records – Each individual has the right to access and request an amendment of his or her medical and clinical treatment, training, or habilitation records and be assured of their confidentiality, in each case as consistent with the individual’s condition and sound therapeutic treatment.

Complaint and Fair Hearing- Every patient has the right to file a complaint if he/she feels his/her rights have been violated in any way; and is entitled to have a timely, fair, and impartial review of any complaint. Every patient is entitled to have legal counsel represent him/her during resolution of complaints. At no time will the filing of a complaint result in retaliatory action on the part of Williamsville Wellness or any of its staff.

Options for Presenting Your Concerns

If you have any concerns, requests, and/or complaints relating to your rights, please talk to any staff member. You may request to be heard by the multidisciplinary treatment team at their regular weekly staff meeting.

The procedure is as follows: Inform staff of the right(s) in question and why you consider said right(s) to have been infringed. You will be given the opportunity to report your concerns to the Director of Williamsville Wellness (or his/her designee). Every effort will be made to resolve the complaint as early as possible. If the staff member is not able to rectify the situation to your satisfaction, you may report your grievance to a human rights advocate who will work to promote and protect your rights. The contact information for the human rights advocate is as follows:

Sharae Henderson
Regional Advocate, Office of Human Rights
Department of Behavioral Health and Developmental Services
Central State Hospital
Phone: 804-524-7247
Fax: 804-524-0235

The Director and Regional Human Rights Advocate will be notified of any allegation(s) of abuse within 24 hours of the allegation(s).

You may exercise your option to contact the Human Rights Advocate at any time.

SUCH COMPLAINT OR GRIEVANCE WILL NOT IN ANY WAY PREJUDICE ANY FUTURE TREATMENT.

Patient Rights and Responsibilities

I have read and understand my patient rights and responsibilities. I further understand any known or suspected abuse should be immediately brought to the attention of the Program Director or Human Rights Advocate. A copy of this signed form will be retained in my record.

Signature: *

Patient Name: *

First

Last