Program Orientation Checklist

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