Intake Package

ORIENTATION SIGNATURE CHECKLIST Name:

Date Of Birth:

Please check the topics your care provider reviewed with you.

I was introduced to Jireh and the Services. I was informed of Jireh’s, the assessors’ and the treatment teams’ qualifications to provide the services. The purpose and process of the assessment was fully explained to me. My family understands how our treatment plan will be developed. My family and I were encouraged to participate in my treatment planning. My consumer rights were explained and a copy given to me. The grievance and appeals procedures were explained and a copy given to me. Jireh provided me with Privacy Practices Notice I received 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. I understand that crisis services will be used for emergencies only. The criteria for transition of my families’ service were explained to me. Costs of Services I know how my services are being paid for. I understand that it is my responsibility to inform Jireh of any changes in my insurance coverage. 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. Consumer Certification I certify that all information given to JCCS is a true and complete statement of my financial circumstances, and that the fees to be charged to me have been explained to me. I understand and accept responsibility for my share of the cost of my treatment. My signature below gives Jireh Counseling and Consulting Service, Inc. the authority to bill and receive payment from any third party Insurance. I understand that I am responsible for any deductibles and/or co-payments and that payment is expected at the point of service. Assignment of Rights: I hereby authorize Jireh Counseling and Consulting Service to carry forward an appeal on my behalf, should they so choose, as permitted by law. I understand that this does not obligate or require Jireh Counseling and Consulting Service to carry forward any such appeal, unless they so choose. I acknowledge that JCCS honors Advanced Directives whenever clinically practicable and will provide me with a referral for legal assistance if requested. Do you have an existing Advanced Directive? []yes []no Follow Up I feel that my visit was held in a private and confidential setting. 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 902-Orientation Signature Checklist

Est. Mar 08

Consent to Treatment I do hereby seek and consent to take part in the treatment provided by this agency. I understand that developing a treatment plan with this therapist/team and regularly reviewing our work toward the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist/team. I am aware that I (or my child) may stop treatment with this therapist/team at any time. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.) I know that I must call to cancel an appointment at least 24 hours before the time of the appointment or as soon as reasonably possible. I am aware that an agent of my insurance company or other third-party may be given information about the type (s), cost (s), and providers of any services I receive. My signature below shows that I understand and agree with all of these statements.

___________________________________ Print Name of Consumer

_______________ Date

___________________________________ Signature of Consumer (or person acting for consumer)

_______________ Date

______________________________________ Relationship of Person Acting for Consumer

I, the therapist, have discussed the issues above with the consumer/family (and/or his or her parent, guardian, or other representative). My observations of this person’s behavior and responses give me no reason to believe that this person(s) is not fully competent to give informed and willing consent. __________________________________ Signature/Title/Credentials

CR101—Consent to Treatment

________________ Date

Est. Mar 08

Your Rights as a Consumer Of Jireh Counseling and Consulting Services Mental Health, Developmental Disabilities, and Addictive Diseases State and Federal laws protect your rights as a consumer of Jireh Counseling and Consulting Services treatment programs. Below is a simplified outline of those rights: Your rights include:

•

The right to receive care suited to your needs.

•

The right to receive services that respect your dignity and protect you health.

•

The right to pertinent information, including the benefits and risks of your treatment, in sufficient time to make informed decisions.

•

The right to participate in planning your own program, and the right to request choice over the composition of the service delivery team.

•

The right to refuse service, unless a physician or licensed psychologist feels that refusal would be unsafe for you and others.

•

The right of referral to legal entities for appropriate representation, and to self-help and advocacy support services.

•

The right to prompt and confidential services even if you are unable to pay.

•

The right to request an opportunity to inspect, copy, and correct your records).

•

The right to exercise all civil, political, personal, privacy and property rights to which you are entitled to as a citizen.

•

The right to remain free of physical restraints or time-out procedures unless such measures are required for providing effective treatment or for protecting your safety or the safety of others.

•

The right to be free of physical abuse, including sexual abuse, and physical punishment.

•

The right to remain free of psychological abuse, including humiliating, threatening, and exploiting actions.

•

The right to file a complaint if you think any of these rights have been restricted or denied. Information on how to file a complaint or contact your Consumer's Rights Representatives is presented on a poster near the reception desk.

CR100—Consumer Rights

RevOct 08

Consumer Rights and Responsibilities Consumer Receipt & Acknowledgement of Rights: My signature below certifies that I have read AND understand completely what my rights are as a participant in Jireh Counseling And Consulting Services, Inc. program.

___________________________ Consumer Signature

______________ Date

___________________________ Consumer Name (Print)

____________________________ Staff Witness

CR100—Consumer Rights

_____________ Date

RevOct 08

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

GRIEVANCE PROCESS Consumer’s Name:

DOB: Consumer Grievance Policy Receipt & Acknowledgement Signature Page

My signature below certifies that I have read AND understand completely what the grievance procedures are as a participant in JIREH COUNSELING AND CONSULTING SERVICES, INC. program. I have received a copy of the Grievance Form

__________________________ Client Signature

______________ Date

__________________________ Client Name (Print)

_________________________ Staff Witness

BH103(b)—Consumer Grievances

_____________ Date

Rev Oct2008

NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment. How We May Use and Disclose Health Information about You For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization. For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection. For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule. You should determine which of these uses and disclosures are permitted in your state for the type of information that you will be using or disclosing. The following language addresses these categories to the extent consistent with the NASW Code of Ethics.

CR103—HIPPA Notice

EstMAR08

NOTICE OF PRIVACY PRACTICES Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are: • Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department) • Required by Court Order • Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. Verbal Permission We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission. With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Your Rights Regarding Your PHI You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Consumer Rights Officer at 5522-C Old National Highway, Suite A, College Park GA, 30349 404 761 0980. • Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies. • Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period. • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request. • Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. • Right to a Copy of this Notice. You have the right to a copy of this notice. COMPLAINTS If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Jireh Counseling & Consulting Services, Inc. at 5522-C Old National Hwy, Ste. A, College Park, GA 30349, or with the Office of Regulatory Services, ORS, Complaint Intake Unit, 2 Peachtree Street, Atlanta, GA 30303 -Telephone (404) 657-5726. We will not retaliate against you for filing a complaint. The effective date of this Notice is June 11, 2007.

CR103—HIPPA Notice

EstMAR08

NOTICE OF PRIVACY PRACTICES RECEIPT AND ACKNOWLEDGEMENT OF HIPPA NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have received and have been given an opportunity to read a copy of Jireh Counseling & Consulting Services, Inc. Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my Privacy Rights, I can contact the Chief Executive Officer, Felicia Jenkins, or Administrator of Jireh Counseling & Consulting Services, Inc. at 5522-C Old National Hwy, Ste. A, College Park, GA 30349 at 404-761-0980 or, or the Metro Regional Office for the Department of Health and Human Services (DHR). . ____________________________________________________ Signature of Consumer, Parent, Guardian or Representative

___________________________ Please Print Name

PLEASE READ: If you are signing as a personal representative of the consumer, please describe your legal authority to act for the consumer or the consumer’s legal guardian (power of attorney, healthcare surrogate, legal guardian, parent) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Signature of Staff Member_______________________________

Date:_____________________

ONLY IF CONSUMER OR GUARDIAN REFUSES TO SIGN COMPLETE BELOW Date: __________________________ Please check here if the following applies: Consumer / Guardian or legal representative refuses to sign:

Signature of Staff Member__________________ Date:_____________________

CR103—HIPPA Notice

EstMAR08

Authorization Request I AUTHORIZE JIREH COUNSELING & CONSULTING SERVICES, INC., ITS AGENTS AND ITS EMPLOYEES (JCCS) TO RELEASE/OBTAIN PROTECTED HEALTH INFORMATION (PHI) ABOUT ME /MY CHILD TO/FROM THE RECIPIENT; FOR THE PURPOSES, AND UNDER THE CONDITIONS DESIGNATED ON THIS FORM.

RECIPIENT

PATIENT Name Address City

State

Date Of Birth

Zip

Phone Number

City

State

Zip

Description of Information to be disclosed: (Guardian should check each item to be disclosed and sign the bottom of form) Diagnostic Assessment Psychosocial Evaluation Psychological Evaluation Psychiatric Evaluation Nursing/Medical Information Medication Management Information

Treatment Plan or Summary Presence/Participation in Treatment Progress in Treatment Current Treatment Update Discharge/Transfer Summary Continuing Care Plan

Educational Information Demographic Information Toxicological Reports/Drug Screens Other Other

Purpose The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. If other purpose, please specify: Please send information requested to: JIREH COUNSELING AND CONSULTING SERVICES, INC. 5522-C OLD NATIONAL HIGHWAY, SUITE A COLLEGE, PARK GA 30349 Phone: (404) 761-0980 Fax Form To: (404) 761-0720 EXPIRATION Unless sooner revoked, this consent expires ONE YEAR FROM THE DATE OF SIGNATURE REVOCATION, DISCLOSURE I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Jireh Counseling & Consulting Services, Inc. at 5522 Old National Hwy, Ste. A, College Park, GA 30349. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization.. FORM OF DISCLOSURE .Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically RE-DISCLOSURE Federal law prohibits the person or organization to whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. Other types of information may be re-disclosed by the recipient of the information in the following circumstances: Medical or life threatening emergency CONDITIONS OF ELIGIBILITY I further understand that Jireh Counseling and Consulting Services, Inc. will not condition my treatment on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences: If services are hindered, clinicians are prevented from properly advocating or acting in the client’s best interest, or a danger is created due to the clients refusal to sign authorization then Jireh Counseling & Consulting Services, Inc. may choose not to continue services to client. SIGNATURES (If signing as a personal representative of an individual, describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.). I will be given a copy of this authorization for my records: Signature of Parent, Guardian or Personal Representative

Relationship

Date

Patient/client refuses to sign authorization Signature of Staff witnessing all of the above

CR701-Authorization to Release PHI

Date

Consent to Publication of Photographs and Film

Please have the consumer complete this consent statement, and then place it in the consumer’s clinical record under the administrative tab.

I, _______________________________ of _____________________________ (Parent/Guardian or Legal Representative name)

(Consumer Name),

hereby consent to being photographed and filmed while attending programs at or with the staff of Jireh Counseling and Consulting Services(JCCS). I further consent to the publication and / or public display of these photographs or film for the purposes of celebrating consumer achievements, consumer advocacy and / or raising awareness of the services provided by JCCS. I also consent to the publication of my name alongside the images.* *Initial if applicable [ ]

This consent is valid for a period of one year from the date of signing. I have the right to withdraw this consent to further photography, filming or publication at any point, save only those images already published under this consent that cannot be reasonably withdrawn.

_____________________________________________ CONSUMER SIGNATURE

_________________ DATE

IF APPLICABLE:

_____________________________________________ SIGNATURE OF REPRESENTATIVE

_________________ DATE

_____________________________________________ RELATIONSHIP TO CONSUMER A REPRESENTATIVE SHOULD DESCRIBE HERE THEIR AUTHORITY TO ACT FOR THE CONSUMER (E.G., LEGAL GUARDIAN,PARENT OF MINOR CHILD)

BH2200—Consent to Publication of Photography, Video and Audiotape

EstMAR2008

Transportation Authorization Form 1. Staff Name: ___________________________ GA Driver License Number: _________________ Exp. Date___________ Name of Insurance Company__________________________ Policy # ______________

2. Staff Name: ___________________________ GA Driver License Number: _________________ Exp. Date___________ Name of Insurance Company__________________________ Policy # ______________

3. Staff Name: ___________________________ GA Driver License Number: _________________ Exp. Date___________ Name of Insurance Company__________________________ Policy # ______________

The above referenced staff member(s) are authorized to use their personal vehicle to transport _________________________________________ for the following reason(s): (Consumer/Family Member) during the course of treatment. ___ Medical Related ___ Educational Related

____ Legal and Court Related Activities ____ Other: _____________________________

I acknowledge that transportation is voluntary and during transportation the staff member will not knowingly or intentionally place me and/or my child(ren) in danger. The staff member has my permission to notify or seek emergency assistance if unforeseen circumstances occur if I am not present that may require any such public emergency official services. My signature below signifies that I agree and release the staff person(s) and the agency from all liability and cost related to transport services.

_________________________________ Parent / Legal Guardian Signature BH3501—Transportation Consent

_________________________ Date Rev Oct2008

We constantly seek to improve our services, so it is important to us to hear from you about any areas of weakness that could be improved. This leaflet explains some of your rights as a consumer, what to do if your rights are violated, and in addition provides some important information for your welfare and safety while receiving services from us. Abuse and Sexual Activity You have the right to be free of physical abuse, including sexual abuse and physical punishment. No staff member should abuse any consumer through physical or verbal attack, exploitation, or coercion. No staff member should engage in any sort of sexual activity with any consumer, or allow sexual activity between or among consumers while the consumers remain under the care or supervision of Jireh Counseling and Consulting Services, Inc (JCCS). If you experience or witness any form of abuse or sexual activity, please report it to a member of staff such as those listed on the consumer rights notices posted in the office. All reports of abuse go to the Consumer Rights Officer. The CRO will investigate the incident (names of this person is located on posters displayed at the service location). The CRO will assist you in making a complaint if you wish (see next section). If the CEO has reasonable cause to believe that the incident constitutes criminal conduct, she will report the incident to the appropriate law enforcement agency. A staff member who is found to have committed abuse will be subject to disciplinary action in accordance with personnel procedures of the board. If a staff member has reasonable cause to believe that a parent of caretaker of a minor has inflicted physical injuries other than by accident, has neglected, exploited sexually or assaulted the child, then the staff member shall notify the executive director or her designee who in turn shall report the allegation to the appropriate County Department of Family and Children Services. We are required by law to report all abuse and neglect of adult consumers in accordance with the provisions of O.C.G.A. 30-5-1--30-5-8. Complaints and Grievances All complaints/grievances should be filed with the Program Supervisor. The name and contact information for the Program supervisor is listed on the back of this brochure and on the crisis calendar. A complaint form is available on request. Complaints may be made in person or by telephone. The Supervisor will assist you in making a complaint if you wish, and will provide you with all the necessary information about complaint and appeal procedures. In brief, these procedures are as follows: As soon as possible, but within 5 working days after your complaint is filed, the Program Supervisor will investigate the complaint and interview those involved as necessary. The Supervisor will attempt to resolve the complaint through BH905—Consumer Orientation Brochure

mediation and conciliation whenever possible. A complaint may be rejected if there is no evidence to support it or if the Supervisor finds that the alleged conduct does not in fact violate your rights. The Supervisor will report to you in writing, to let you know the decision. If your complaint is rejected or is not resolved by the Supervisor to your satisfaction (or your guardian or parent if you are a child), you may request a review of the decision by writing to the Consumer Rights Officer within 15 days. The CRO should complete his / her review in a timely manner and report back to you in writing within 5 days. If you are not satisfied with the outcome of the CRO’s review, you (or your parent or guardian) may request a further review by the CEO by filing a written appeal within 10 days of notification of rejection notice or other decision. Within 5 working days of the filing of your appeal, the CEO or his/her designee shall issue a decision disposing of the appeal. The CEO may affirm, reverse, or modify the CRO’s decision or s/he may return the case to the CRO for further proceedings. In no event shall the period for completing the further proceedings exceed 5 working days. The decision of the CEO is final. The CRO and the complainant shall be notified of the decision. General provisions are as follows: 1. Staff members who are involved in a complaint shall not be involved in the processing of that complaint. 2. No person shall be subject to any form of discipline, or reprisal solely because he has sought a remedy through or participated in the procedure outlined in this section. 3. Obstruction of the investigation or disposition of a complaint by any person shall report to the JCCS CEO or designee, who shall take action to eliminate the obstruction. Staff members are subject to adverse action engaging in such obstruction, in accordance with personnel procedures of JCCS. 4. Time limits designed in this Section may be extended by the decision-maker at each step for good cause only. Outcomes Management System and Satisfaction As indicated within the Jireh mission as listed at the top of this pamphlet, JCCS strives to provide a high level of quality services. In order to continue to monitor the quality of services and consistently improve services, JCCS has developed a quality improvement process based on NIAtx Plan, Do, Study, Act. Results are reviewed by a Performance Improvement Committee then submitted to leadership. Among the indicators is consumer satisfaction. Consumers are given an intake satisfaction survey within their orientation packet and are encouraged to complete it and return it to the designated box. All JCCS staff have Consumer Satisfaction Surveys for consumers to complete and provide feedback to the agency. All surveys are forwarded to the Quality Improvement Officer quarterly for result tabulation.

Confidentiality Why we collect information and how we use it. We will collect medical (health) information about you in order to provide you with services that match your needs. We will use and disclose that information in order to manage your health care and treatment, to obtain reimbursement for treatment, and to meet quality control and other government requirements. We will not disclose any personal information about you to anyone else without your prior approval and consent, except as permitted or required by law. Your Rights to Review and Correct Information. You have the right to reasonably review and request corrections to confidential and non-confidential information about you that is held in our records. Our Policies and Practices to Protect the Confidentiality and Security of Information. We restrict access to personal information about you to those who need to know that information to provide services to you. All employees and staff are required to comply with our established confidentiality procedures and policies. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your personal information. A full description of our privacy practices is contained in our Privacy Practices Notice. You will receive a personal copy (without charge) on request to the receptionist. If you have any questions or concerns about the privacy of your personal health information, or to complain if you believe your rights or the rights of someone else have been violated, please contact our Corporate Compliance Officer at 404-761-0720.

OR YOU MAY WRITE OR CALL - Office of Regulatory Services, ORS, Complaint Intake Unit, 2 Peachtree Street, Atlanta, GA 30303 -Telephone (404) 657-5726

Medications You have the right to know the benefits, side effects, and risks of any psychotropic medication that may be prescribed for you. The attending physician is responsible for assuring, and documenting in your medical record that the benefits, side effects, and risks of medications have been explained to you and your family. You or your parents or legal guardian will be asked to give signed consent for the administration of all medications. Open Door Policy JCCS maintains an open door policy that guarantees access to program leadership up to the CEO in person, in writing or by telephone, or through e-mail. Restraints/Seclusion The use of personal restraints and seclusion by JCCS personnel is prohibited. Smoking/Tobacco Use The use of tobacco in any form is prohibited in all JCCS facilities. Tobacco use is also prohibited in staffs’ personal vehicles during times when consumers are being transported. There are designated smoking areas outside of the facility. Est. Mar 08

Weapons No weapons of any kind are allowed on JCCS property. Illegal/Legal Drugs JCCS offers a drug free environment. Illegal drugs are prohibited on any property owned leased or rented by the agency. Legal drugs, including prescription and nonprescription must be in original packaging identifying contents, recommended dosage, and frequency. Any medications that will be housed on agency property will be placed in a secure area under close supervision.

Hours of Operations Office Hours Monday 8:30 AM – 6:00 PM Tuesday 8:30 AM – 6:00 PM Wednesday 8:30 AM – 6:00 PM Thursday 8:30 AM – 6:00 PM Friday 8:30 AM – 6:00 PM 1st and 3rd Saturday

Treatment Team JCCS holds weekly multidisciplinary treatment team meetings to develop consumer treatment plans review treatment progress modify levels of care and authorize consumer discharges. The treatment team assessed appropriateness of treatment interventions relative to consumer needs accuracy of assessment feedback from the consumer and significant others. The group is reflective of the cultural diversity of the area population and consumers served. Service Coordination A service coordinator will be assigned at the point the intake process is complete and treatment is authorized. Cost of Services It is the policy of JCCS that all consumers will be charged fees for services received according to the current rates in effect at the time of service. A sliding fee scale may be applied to charges based on the consumer’s, or family’s, verified income. No individual will be denied service because of verified inability to pay. JCCS 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.

Advanced Directives JCCS will honor any advanced directives that you have made for your health care if they have been reviewed and approved by our Medical Director. If you wish to make such an advanced directive, please submit it to your provider in the first instance. Safety Evacuation plans are located on maps hanging on walls. JCCS Safety Code is as follows. Red...................................................................... Internal Disaster Blue .................................................................Medical emergency Green ........................................... .Workplace threat and violence Gray....................................................................... Severe weather Flashlights and first aid kits are located in the place that is indicated on the evacuation maps. Drills are conducted quarterly and consumers will participate in drills. Good hand washing is the best way to prevent the spread of germs. Exit signs are located at every exit.

BH905—Consumer Orientation Brochure

10:00 AM – 2:00 PM

Consumer Orientation Information

After Hours Access Intensive Family Intervention JIREH EMERGENCY

(404) 761-0980 CORE Services – Community Support Individual Behavioral Health Link (SPOE)

1-800-715-4225 Medication Emergency-Poison Control

(404) 616-0000 My Treatment Team Name

Phone Number

___________________________________________ My Service Coordinator ___________________________________________ My Program Supervisor ___________________________________________ ___________________________________________ ___________________________________________ JIREH COUNSELING & CONSULTING SERVICES, INC. 5522-C Old National Highway, Suite A College Park, GA 30349 (404) 761-0720 (office) (404) 761-0980 (fax) [email protected]

Est. Mar 08

Our Mission Our mission is to create and deliver high quality in-home, community-based, schoolbased, and out-patient mental health and substance abuse services that improves the health and well being of children, adolescents, and their families.