Ifi Intake Package

PROGRAM ORIENTATION CHECKLIST Name:

Date Of Birth:

Please initial the topics your care provider reviewed with you.

I am participating in the (check one) Intensive Family Intervention (IFI) Program CORE Services I was informed of Jirehs’ and the treatment teams’ qualifications to provide the services. The purpose and process of the services were fully explained to me. My family understands our treatment plan My family and I received a copy of the treatment plan. I received a program Consumer Orientation Brochure on my initial visit which includes mission statement, Hours of Operations, After Hours access, policy on abuse, complaints and grievance procedures, outcomes management system and satisfaction, reporting, medication, open door policy, restraints/seclusions, smoking policy, weapons, illegal/legal drugs, Treatment Team, Service Coordination, Costs of Services, Safety and Advanced Directives Information was presented to me in a manner that was clear and understandable. My care program, treatment team visits and treatment responsibility were fully explained to me. My family has a safety plan and I know what to do in case of a crisis. I know who the members of my team are and how to contact them. I have received a copy of the transportation consent form. I understand that crisis services will be used for emergencies only. The criteria for transition or discharge of my families’ service were explained to me. Costs of Services I know how my services are being paid for. I understand it is my responsibility to immediately inform my care manager in the event of any changes in my insurance. No individual will be denied MRO service because of verified inability to pay, you may be referred to other resources. Jireh Counseling and Consulting Service does reserve the right to refuse services to any individual who is determined to be able to pay but is unwilling to pay according to policy. Follow Up I feel that my visit was informative and respectful my confidentiality was respected. I know who is responsible for my service coordination. I KNOW WHAT HAPPENS NEXT Signatures

Signature of Consumer/Representative*

Date Signed

Signature of Care Provider

Relationship *Parent/legal guardian’s signature in the case of a minor or custodian’s signature in the case of an adult in custodial care.

BH 103-Program Orientation Signature Checklist

Est. Mar 08

Intensive Family Intervention (IFI) Intensive Family Intervention Services are short-term, family-focused, and community-based services designed to help families cope with significant stresses or problems that interfere with their ability to nurture their children. The goal of the Intensive Family Intervention Program is to maintain children with their families, or to reunify them, whenever it can be done safely. Intensive Family Intervention may be provided to different types of families— birth or biological families, kinship families, foster families, and adoptive families—to help them address major challenges, stabilize the family, and enhance family functioning. IFI grew out of the recognition that children need a safe and stable family and that separating a child from their family is a traumatic experience, often leaving lasting negative effects. These services build upon the conviction that many children can be safely protected and treated within their own homes when parents are provided with services and support and empowered to change the child’s and their lives.

Team Approach IFI services are delivered utilizing a team approach and are provided primarily to youth in their living arrangement and within the family system. Your team will consist of: 1. Licensed Therapist—to provide professional counseling and therapy. 2. Family Intervention Specialist (FIS)—to help your family learn critical skills to improve family functioning. 3. Consumer Support Specialist (CSS)—to help you & your family connect to community resources. Team members will visit you individually through the week. At the onset of services your team may spend 3 or more days a week with you and your family or guardians, as the risk of out-of home placement decreases or the reunification process is less stressful to the family your team will begin to decrease the number and length of visits. One of the team members will be assigned as your Case Manager. Your case manager will have a small caseload allowing them to focus more time on your family and ensuring that your family moves through the service toward recovery. IFI services are generally offered for 90 days and IFI team members are available 24 hours a day in the event of an emergency. Many of the services your family will receive will be in your home or in another environment familiar to the family.

Services Our IFI Program offers the following services: ƒ

Individual & Family Counseling

ƒ

Physician Assessment and Care

ƒ

Individual & Family Training

ƒ

Nursing Assessment and Care

ƒ

Diagnostic Evaluations and Assessment

ƒ

Case Management

ƒ

Treatment Planning

ƒ

Crisis Intervention

Remember your team of professionals & all of the Jireh Staff wants to help you and your family, please do not hesitate to let us know what you need.

IFI Program Description

Jireh Counseling and Consulting Service, Inc.

EstAUG08

Jireh Counseling & Consulting Services Jireh has been conducting business in the local area for many years. We have worked hard to gain the respect of the surrounding communities and other agencies. This recognition is due to our respect for our consumers and fellow colleagues. It is our sincerest hope that your experience with us will further this reputation of personalized service and consumer satisfaction. Our company is comprised of people who live in the surrounding communities and have knowledge of each neighborhood, the schools, and community resources to meet our consumer’s needs. We are a private counseling agency that serves individuals, families, and communities through education, training, and therapeutic counseling. Our staff is well trained and educated on providing counseling and training services.

Felicia Jenkins, LPC CEO & Program Director

Nureava Darden Consumer Rights Officer

Byron Kellam, LPC IFI Team Leader

Adrienne Johnson, LMSW CORE Services Supervisor

Mission Statement Our mission is to create and deliver high quality in-home, community-based, school-based, and outpatient mental health and substance abuse services that improve the health and well being of children, adolescents, and their family.

Jireh Services The staff at JCCS are dedicated to providing our consumers will unsurpassed, high-quality services. We are committed to the following principles: Service Delivery—We commit to providing excellence which guides all operating decisions at Jireh Counseling & Consulting Services, Inc. Simply put, it is the way we do business. We will provide timely, professional, effective, and efficient service to all of our consumers. Ethical and Fair Treatment for All—We are committed to forming relationships of fairness and trust with our consumers and our employees. We will conduct our business according to the highest ethical standards. Compassion—We will never lose sight of the fact that we provide care and comfort to people in need. The individuals and families that rely upon us are fellow human beings, and receive respectful and dignified treatment from all of our staff at all times. For more information please check us out online at—www.jirehcounseling.com or contact us @: (office) 404 761- 0980—(fax) 404 761-0720 [email protected]

IFI Program Description

Jireh Counseling and Consulting Service, Inc.

EstAUG08

GRIEVANCE PROCESS Consumer’s Name:

DOB:

Jireh values the involvement of members in the organization and functioning of the agency. As a Jireh Counseling and Consulting Services, Inc. consumer you have a right to register formal complaints about specific issues relating to the general operation and management of the agency. You also have additional rights to appeal decisions regarding the planning and delivery of the individualized services you receive from the agency. Filing a formal grievance or appealing a decision regarding your services will never result in any retaliation or barriers to services. These are the steps you should follow if you are dissatisfied with any aspect of the general operation and management of the agency or if you wish to appeal decisions regarding the planning and delivery of individual services: STEP

Talk about the problem right away with your counselor. Try to resolve the problem. Most concerns can be resolved by just talking it over with the responsible staff members.

STEP

If you feel that your concern was not resolved to your satisfaction after STEP ONE, you may file a formal grievance with your program's supervisor. The program supervisor must respond to your request in writing within five working days.

STEP

If you feel that your concern was not resolved to your satisfaction after STEP TWO, you may file a complaint with the Clients Right Officer. They will help you document your concern in writing and will investigate it by meeting with the individuals involved and reviewing any related records. The CRO will provide a written response to your request within five working days following the meeting. At your request, they will also give you information about external agencies that provide advocacy and/or legal services in the community.

STEP

If you feel that your concern was not resolved to your satisfaction after STEP THREE, you may request a review of the decision by the CEO. The CEO will meet with you within ten working days following your request. They will investigate and document your concern and issue a decision, in writing, to you within ten working days following the meeting with you. Decisions by the CEO are final. The only exceptions are for appeals of individual services such as denial of services (i.e. program suspensions), changes in service plans or refusals to change service plans and/or termination from service. In these cases there is one more step you may take.

STEP

If your concern is about the specific services you receive at Jireh Counseling and Consulting Services, Inc. and involve: ¾ denial of services ¾ change of service plan ¾ refusal to change service plan ¾ termination from services You have a right to appeal the CEO decision (STEP FOUR) to Office of Regulatory Services, ORS. Complaint Intake Unit, 2 Peachtree Street, Atlanta, GA 30303 Telephone (404) 657-5726

BH103(b)—Consumer Grievances

Rev Oct2008

Consumer Grievance/Complaint Form COMPLAINTANT Name: Address:

Phone #:

Case Manager: Program: DETAILS Problem/Grievance/Complaint (List of who, what, when, where, why, etc.):

What do you think needs to be done to solve this problem? What do you expect to do to solve your problem? What is the relief you desire?

Who have you talked to about this problem?

Additional Remarks:

SIGNATURES

Cient Signature

Name (print)

Date

Received By (JCCS Staff member)

Name (print)

Date

BH104(b)—Consumer Grievances

EstNovt2007

Jireh Steps Intake

We will assess your child or family, to determine how we can best serve you.

Program

This is when your team will work with you & your family and plan for your discharge.

Transition Discharge

If your family will best be served by another Jireh service then we will plan with you to move to another service. Your finished. We will call you a few months after you leave our service just to check-in.