Client Intake

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    PART I – DEMOGRAPHIC INFORMATION
    First Name:*
    Middle Name:
    Last Name:*
    Suffix (if applicable):
    Alias(es):
    SSN:*
    DOB:*
    Gender:*

    Marital Status:*
    Race:*

    Tribal Affilliation:

    PART II – CONTACT INFORMATION

    Email Address:*

    Drivers License Number:
    Drivers License Expiration Date:



    Home Address:
    City:
    State:
    Zip Code:


    Mailing Address:
    City:
    State:
    Zip Code:

    Cell Phone Number:
    Home Phone Number:
    Emergency Contact Name:
    Relationship:
    Cell Phone Number:
    Home Phone Number:

    Address:
    City:
    State:
    Zip Code:

    Total Number of Minors:

    Please list names of your kids or minors in the home where you reside below:
    Name of Child:
    DOB:
    Relationship:

    Name of Child:
    DOB:
    Relationship:

    Name of Child:
    DOB:
    Relationship:

    Name of Child:
    DOB:
    Relationship:

    Name of Child:
    DOB:
    Relationship:

    Are you a daycare provider?*
    Are you Pregnant?*

    PART III – PROGRAM/FEE AGREEMENT
    Are you employed?*
    If yes, where?
    Wage:

    Do you receive SSI/SSDI?*
    If yes, ammount:

    Medical Insurance Provider:
    Insurance Card Number Active Date:

    I agree to pay for my programming if not covered by subsidy, indigence, or insurance. If eligible, I authorize the release of any medical or other information to process claims through insurance. I authorize payment of my insurance to be paid directly to the provider of service. I understand all fees must be paid in advance of service unless otherwise determined. I understand that if I am unable to keep to my payment schedule, I will contact the BACS office before my payment due date to make arrangements. I agree that any subsidy or indigence payment may be withdrawn due to non-compliance. I further understand that if I fail to abide by the established fee agreement, my file may be terminated and returned to court/referring agency for further action.

    Any money paid in advance will be transferred to clear debts in other BACS programs. My fees may be forfeited if I am terminated for non-compliance. I understand that I may not get credit with the Courts/referral source until my fees are paid in full.

    I authorize BACS to contact me at the numbers provided on this form. Text Reminders: I have been given the option to receive text-message courtesy reminders on my cell phone. I understand that message and data rates may apply, and I may be charged by my wireless carrier. I authorize BACS to send an email, leave a voicemail, send a text message, or leave a message with my emergency contact, if necessary, for me to contact BACS.

    Client printed name:*
    Signature:*
    Date:*


    Guardian printed name:
    Signature:
    Date:

    PART IV - MEDICAL INFORMATION

    Have you ever been in treatment for drug and/or alcohol abuse?*

    Are you currently using drugs?*
    If yes, drug(s) of choice?


    Have you used drugs in the past?*
    If yes, date of last use:


    Have you ever injected drugs (IV use)?*
    If yes, date of last injection:


    PART V – OTHER INFORMATION (FOR STATISTICAL PURPOSES ONLY)

    Highest grade level completed:

    Are you currently under supervision with State P&P?
    If yes, name of Supervising Officer:


    Are you on any other monitoring with another agency?
    If yes, what type of monitoring?
    With which ageency?


    Birth City:
    Birth State:


    What town/city do you consider to be your home?

    FINANCIAL ELIGIBILITY

    Full Name:*
    Date:*


    Social Security Number:*
    DOB:*


    Are you covered by health insurance?

    Insurance Company:
    Name of insured:


    Group #:
    Member ID Number:


    Is person covered by Medicaid?

    Employment

    Present Employer:
    Phone Number:


    Hourly Wage:
    Monthly Salary:


    Average # of Hours Worked Per Week:

    Length of employment with present employer:

    Pay Frequency:

    Monthly Total:

    If unemployed, how long since employed?

    Are you currently seeking work?

    Are you currently receiving unemployment compensation?

    Are you or someone in your family unit receiving unemployment income?

    If yes, how much per month?

    Marital Status:

    Spouse’s Name:

    Place of Employment:

    Hourly Wages:
    Monthly Salary:


    Average # of Hours Worked Per Week:

    Length of employment with present employer:

    Pay Frequency:

    Monthly Total:

    Add up all income per month:

    ALLOWABLE LIABILITIES/DEDUCTIONS PER MONTH:

    Pre-Tax Contributions:

    Pre-Tax Health Insurance Cost:

    Pre-Tax 401k/403B Etc. Contribution:

    Pre-Tax HSA/Flex Spending Contribution:

    Moving Expenses:

    Student Loan Interest:

    Tuition and Fees:

    Itemized Medical Expenses (must be 10% of gross annual income or higher):

    Total allowable liabilities per month:

    Adjusted Monthly Income to determine Eligibility for Block Grant funded Services (Monthly Income – Allowable Liabilities):

    Adjusted Annual Income (Adjusted Monthly Income x 12 Months):

    Number of family members dependent on taxable income:(Includes client + spouse (if applicable) + #children (if applicable):

    Ages of Children in House:

    I will provide the following documentation:

    Other Income (Unemployment, TANF, Significant Other Income):

    By signing this form, I am verifying the above amounts are correct to the best of my knowledge. I understand that a minimum monthly payment is due by the 25th of each month until my account is paid in full. I understand I will only be billed for number of group sessions attended. However, INDIVIDUAL SESSIONS WITHOUT 24 HOURS NOTICE MAY BE BILLED A $25.00 NO-SHOW FEE. I am also aware that I need to report significant changes in my household income (ex: pay increase or decrease, new job or loss of job, change of people in household) immediately.

    Client Printed Name:
    Date:*


    Client Signature:*
    Date:*


    BACS Staff Printed Name:
    Date:


    BACS Staff Signature:
    Date:


    Parent/Legal Guardian Printed Name:
    Date:


    Parent/Legal Guardian Signature:
    Date:

    FINANCIAL RIGHTS AND RESPONSIBILITIES

    I am providing information on this form that is true to the best of my knowledge.

    I must provide proof of eligibility for benefits. I may receive help in gathering documents or contacting individual or agencies by calling (406) 443-2343

    I know the information I have given may be reviewed and verified by a representative of the State of Montana or Boyd Andrew Community Services (BACS). I also understand that I must cooperate fully with state, federal and BACS staff if my case is reviewed. By signing this application, I have given my permission for the State of Montana and BACS to obtain verification and information necessary to determine my eligibility or my children’s eligibility. I understand that my permission includes the use of my social security number and/or my children’s social security number to obtain the information.

    I know the information I have given is confidential. I agree that medical information about me or my children can be released only if needed to administer, including billing for, the services received. Information will be forwarded to other agencies or organizations only if I have given my permission by signing a release.

    If my child or I are enrolled in Medicaid, health insurance or other third parties, payments are automatically assigned by law to the State of Montana. Montana law requires that any money received by my household for medical expenses that are previously paid by Medicaid must be reimbursed to the State. Health insurance and third party payments for services received at BACS must be reimbursed to BACS.

    I understand that I may request a Fair Hearing if I disagree with any action taken as the application for health care is processed, and that the request for Fair Hearing must be in writing.

    If I qualify for Medicaid, am otherwise uninsured, and do not wish to apply for Medicaid, I understand I will be charged full price for services received.

    If I qualify for Block Grant funding, but do not supply the required financial documentation to receive this funding, I understand I will be charged full price for services received.

    I know this application will be considered without regard to race, color, sex, age, handicap, religion, national origin, or political belief.

    If I knowingly give false information on this form I understand that I must reimburse Boyd Andrew Community Services for any cost incurred.

    I have read and understand the financial obligations of this agreement.

    Client Printed Name:
    Date:*


    Client Signature:*
    Date:*


    BACS Staff Printed Name:
    Date:


    BACS Staff Signature:
    Date:


    Parent/Legal Guardian Printed Name:
    Date:


    Parent/Legal Guardian Signature:
    Date:

    GENERAL INTAKE INFORMATION CHECKLIST

    The following information has been provided as part of the client orientation. A check of the items and the signatures below indicate that each area has been fully explained to the client.




    I acknowledge that I have been informed of my client’s rights and have received a copy of the Rights and grievances and appeal procedures and a copy of this form.

    Client Printed Name:
    Date:*


    Client Signature:*
    Date:*


    BACS Staff Printed Name:
    Date:


    BACS Staff Signature:
    Date:


    Parent/Legal Guardian Printed Name:
    Date:


    Parent/Legal Guardian Signature:
    Date:


    CLIENT ORIENTATION INFORMATION
    Services Provided at Boyd Andrew Community Services (BACS)

    Therapeutic methods, philosophies, and orientations shall be determined by management. BACS offers the following required services:

    Crisis Intervention: The process of intervening in a crisis to encourage appropriate treatment of substance use disorders.

    Screening and Evaluation: The process of collecting information, which will indicate diagnosis and appropriate treatment.

    Individual Counseling: Face-to-face interaction between a licensed or eligible Licensed Addiction Counselor (LAC) and an individual client. Unless otherwise specified in the job description, counselors are expected to carry a client caseload of 1-20 at a minimum.

    Group Counseling: Face-to-face interaction between two or more clients and a licensed or eligible Addiction Counselor(s) for a specific therapeutic purpose.

    Family Counseling: Face-to-face interaction between a licensed or eligible Addiction Counselor and family member(s) with or without the client for a specific therapeutic purpose.

    Intervention Services: The process of intervention to assist a person in acknowledging the existence of SUD problems in his/her life and to facilitate appropriate treatment.

    Structured Sessions in Education/Prevention: A group of assignments designed to give individual clients information and understanding concerning the recovery process.

    ADDITIONAL SERVICES
    Intensive Outpatient Program: (ASAM 2.1), (IOP), treatment of substance uses to families and individuals through a structured series of lectures and group therapy. The lecture portion of the treatment series is designed to educate individuals and families about substance use, abuse or dependency, and life skills necessary to live a chemically free lifestyle. The therapy groups for individuals and families offer a therapeutic environment necessary for behavior alteration, exploration of feelings, confrontation of defenses and self-destructive behavior, self-assessment, and insight. The family portion of the treatment series brings together members of families in treatment and focuses both on understanding how families become dysfunctional with substance use and alternatives available to restore family functioning.

    Outpatient Program: (ASAM 1.0) (OP) Individual sessions every other week and group therapy once a week.

    Co-Occurring Disorder Program: (COD) Individual sessions, weekly, bimonthly, or monthly and group therapy once a week.

    Prime for Life (PFL) – is the evaluation component utilized to identify substance use patterns of the offenders and to make appropriate recommendations for education and/or treatment. A complete biopsychosocial assessment is required in all cases in which treatment is recommended. Misdemeanor dangerous drug offenders may complete the assessment with the PFL program or a state approved treatment program which offers a Major Depressive Disorder (MDD) education program. Education group is component based on curriculum contained and explained in the PFL course curriculum manual. The course will be based on the PFL curriculum but must contain specific information on misdemeanor drug laws.

    Group Only Program: Weekly groups – Anger Management, Parenting, Co-Dependency, Seeking Safety, MRT, Batterers Intervention,

    The specific content and duration of all treatment services is determined by the presence and nature of the most current version of ASAM placement continued stay criteria. Criteria are identified at admission and during periodic continued stay reviews.

    Client Printed Name:
    Date:*


    Client Signature:*
    Date:*


    BACS Staff Printed Name:
    Date:


    BACS Staff Signature:
    Date:


    Parent/Legal Guardian Printed Name:
    Date:


    Parent/Legal Guardian Signature:
    Date:

    CONSENT TO TREATMENT AND ADMISSION INFORMATION

    Client Name:
    Date:*


    The minimum length of groups/programs varies. Dependent upon my participation, homework assignments, and presentation of material, it may take longer. I understand that I may be responsible for all/some of the cost of the program.

    I know I have the right to be free from verbal, mental, or physical abuse, neglect, and financial exploitation by staff and group members. I understand facilitators are required, per policy, to report any confirmed or suspected violation of agency rules by a client. Facilitators, by law, must also report potential child abuse, new crimes, and potential harm to self and/or others.

    Children cannot attend groups with a parent/guardian. Childcare needs to be arranged in advance of your group.

    By signing below, I acknowledge that I have been given a copy of HIPAA and confidentiality guidelines and understand them. I understand I must sign a Release of Information for my records to be given to anyone outside of Boyd Andrew Community Services. It shall be my responsibility to maintain the highest level of confidentiality towards my peers. Any violation of the confidentiality of my peers will be a program violation, and I will be immediately terminated from the program and my paperwork returned to my referring agency. I am aware that my counselor has rights and privileges afforded to that profession by law, and therefore my counselor will share with other members of the counseling staff any information pertinent to my participation in the Boyd Andrew Community Services program.

    If I refuse treatment or I do not choose the recommended treatment, the possible consequences of this decision will be explained by my counselor. I understand I may be terminated from the program and reported to my referring agency for non-compliance. The recommendations for services may include infectious disease screening, prevention, and treatment information, follow up alcohol and drug treatment recommendations or dangerousness and violence assessment recommendations, if appropriate.

    By signing below, I acknowledge that I agree to the rules and guidelines for receiving treatment with Boyd Andrew Community Services. I understand that if I have a grievance towards staff or the program, I have the right to report it verbally or in writing to my counselor, my program manager, or the compliance officer. If I chose to file a grievance, I understand I may be asked to follow up with a supervisor to investigate my grievance. A grievance form can be requested from any Boyd Andrew Community Services staff member and submitted in a plain envelope to maintain confidentiality. I received a copy of this form at intake and understand I can ask for additional copies at any time while in the program.

    If you are participating in services through tele-treatment services, we take extra steps to protect your confidentiality by using a secure network and using passcodes to access the links. If we have concerns about your safety or the safety of others, we have a duty to contact emergency services where you are located.

    You may be asked to submit a random breathalyzer and/or urinalysis drug test at any time while enrolled in treatment. Failure to submit to do so may make me ineligible for group. In that regard, I voluntarily agree to submit to this alcohol and drug testing. If I am found under the influence in group, I will be removed and receive an unexcused absence.

    I agree to pay for my programming if not covered by subsidy, indigence, or insurance. If eligible, I authorize the release of any medical or other information to process claims through insurance. I authorize payment of my insurance to be paid directly to the provider of service. I understand all fees must be paid in advance of service unless otherwise determined. I understand that if I am unable to keep to my payment schedule, I will contact the BACS office before my payment due date to make arrangements. I agree that any subsidy or indigence payment may be withdrawn due to non-compliance. I further understand that if I fail to abide by the established fee agreement, my file may be terminated and returned to court/referring agency for further action.

    Any money paid in advance will be transferred to clear debts in other BACS programs. My fees may be forfeited if I am terminated for non-compliance. I understand that I may not get credit with the courts/referral source until my fees are paid in full.

    I authorize BACS to contact me at the numbers provided on this form. Text Reminders: I have been given the option to receive text-message courtesy reminders on my cell phone. I understand that message and data rates may apply, and I may be charged by my wireless carrier. I authorize BACS to send an email, leave a voicemail, send a text message, or leave a message with my emergency contact, if necessary, for me to contact BACS.

    Client Printed Name:
    Date:*


    Client Signature:*
    Date:*


    BACS Staff Printed Name:
    Date:


    BACS Staff Signature:
    Date:


    Parent/Legal Guardian Printed Name:
    Date:


    Parent/Legal Guardian Signature:
    Date:

    TELEMEDICINE CONSENT

    Client Name:
    DOB:*


    My provider will explain to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my provider.

    I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
    I will have the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation.

    In an emergency, I understand that the responsibility of the treatment provider is to notify local emergency personnel or law enforcement.

    I will have a direct conversation with my provider, during which I had the opportunity to ask questions regarding telemedicine treatment. My questions will be answered and the risks, benefits and any practical alternatives will be discussed with me in a language in which I understand. By signing this form, I certify:

    That I have read or had this form read and/or had this form explained to me.

    That I fully understand its contents including the risks and benefits of the procedure(s).

    That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

    Client Printed Name:
    Date:*


    Client Signature:*
    Date:*


    Parent/Legal Guardian Printed Name:
    Date:


    Parent/Legal Guardian Signature:
    Date:

    TREATMENT RULES AND EXPECTATIONS, RIGHTS, AND CONFIDENTIALITY NOTICE

    I understand that I will be responsible for the cost of services rendered if not covered by insurance. I am responsible for paying for all groups at time of the session.

    I must be present, with treatment group book/materials, paid for group, and ready to go to group when the facilitator arrives to escort group to classroom. No late entries will be allowed in group, and I will not be allowed to stay without my book/materials.

    Attendance is mandatory and only verified emergencies are excused. Work is not an excused absence unless authorized by counselor or facilitator. If I am late for group, I will not be allowed late entry. I must call in person to obtain an excuse before missing a class.

    Unexcused absences may be put into non-compliance status and can result in disciplinary procedures.

    I understand I am expected to show respect towards all Boyd Andrew Community Services staff, group members, and facilitator(s), especially while others are talking. While assignments are being presented in group, I am expected to be respectfully attentive and participate in group discussion and feedback. No sleeping during group. What is said in group stays in group. There is to be no crosstalk while other group members are talking. I am expected to give and to receive feedback in a respectful & helpful manner. There is no rescuing, especially supporting negative thinking and behaviors. Swearing or derogatory comments/statements will not be tolerated. The facilitator reserves the right to remove me for any inappropriate attitude, behavior, or language and may result in disciplinary procedures.

    No disruptive actions, noises, behaviors, or physical violence will be allowed during group. I will be warned once, and after that will be dismissed from group. Any dismissal from group will count as an unexcused absence.

    There is to be no use of tobacco, vaping, or any marijuana products while participating in this program, and while on camera. To respect all participants please do not have any triggering items in view of the camera.

    You are responsible for maintaining program confidentiality. In order to participate in the group, you must be in a private space, without distractions. This space should be a quite space, so that you are able to listen and participate accordingly.

    I understand that I cannot use mood altering substances, including alcohol, during the time I am enrolled in this program. You may be asked to submit a random breathalyzer and/or urinalysis drug test at any time while enrolled in treatment. Failure to do so may make me ineligible for group. In that regard, I voluntarily agree to submit to this alcohol and drug testing. If I am found under the influence in group, I will be removed and receive an unexcused absence. Use violations may result in a referral to a higher level of care.

    I understand that it is the policy of Boyd Andrew Community Services which prohibits discrimination in accepting referrals on the basis of sexual preference, gender, disability, race, creed, religion, political views, or national origin. If I need an accomodation for a disability, I know it is my responsibility to notify my program manager or counselor.

    I understand that I am required to attend all required appointments with my Counselor which may include additional evaluations or meetings (i.e., Dangerousness and Violence Risk Assessment or Chemical Dependency Assessment, exit interviews, and/or treatment plan meetings) and may include a discharge/transition plan.

    Client Printed Name:*
    Date:*


    Client Signature:*
    Date:*


    Parent/Legal Guardian Printed Name:
    Date:


    Parent/Legal Guardian Signature:
    Date: