Source: https://renaissanceranchogden.com/full-client-intake-form/
Timestamp: 2020-08-09 10:35:12
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Renaissance Ranch Ogden Full Client Intake Form | Renaissance Ranch Ogden NEED HELP NOW?
Renaissance Ranch Ogden Full Client Intake Form
Home / Renaissance Ranch Ogden Full Client Intake Form
Full Renaissance Ranch Ogden Intake Form
1 New Client Application
2 Treatment Contract
3 Non Refundable Policy
4 Insurance Claims Policy
5 Consent to Service
6 Client Rights
7 Follow-Up Services
8 Release of Information
9 Program Rules & Conduct
10 Family Confidentiality Agreement
Referred By Agency Name
As a client in the Renaissance Ranch Treatment Program, I agree to the following:
I will keep what I hear and see in the group confidential
I will identify with my own issues
I will think about my life in depth and detail
I will identify triggers that lead to compulsive behavior and discuss them in group with my Counselor
I will practice openness and emotional honesty and I will not keep secrets
I will give and receive support and feedback
I will bring needed materials to the group
I will complete all assignments in depth and discuss them with my Counselor
I will be honest and open minded about my recovery
I have read and understand the requirements above and will abide by the rules.
I understand that upon intake of Renaissance Ranch; there is a $500 no-refundable fee for assessments and intake costs. This is the responsibility of the client regardless of how many days you attend.
I understand all fees are non-refundable after 90 days of treatment.
I hereby agree to sign over all insurance payments to Dave Rose that may be received through the US Postal service to the policy holder; I agree to sign all funds over to Renaissance Ranch immediately.
If I fail to do so, I will be legally responsible for all non-relinquished sums from the insurance company, as well as the amount it costs to retrieve those funds though collections.
I authorize Renaissance Ranch to provide addiction treatment services according to the rules and regulations of Renaissance Ranch. These services will be coordinated between the client and the appropriate Renaissance Ranch Staff
I consent to possible searches of my personal belongings by authorized staff whenever conducted, announced or unannounced. I further agree to participate in blood, urine, breathalyzer or other alcohol, or drug testing whenever asked by authorized staff.
I am also giving permission in the event of an emergency for Renaissance Ranch staff; to administer first aid or CPR and/or be transferred to the nearest hospital in the event of a medical emergency. I also agree to not hold Renaissance Ranch or its staff responsible for any injury or ham that may occur doe to first aid/CPR actions.
The following notice will Accompany Any Disclosure
This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR part 2) The Federal rule prohibits you of making any further disclosure of this information unless further disclosure is expressly permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute an alcohol or drug patient.
Each Renaissance Ranch client has the right to:
Be treated with love, dignity, acceptance, and respect by Staff and other clients
Be fully informed of his/her rights
Be fully informed of any changes or fees associated with Renaissance Ranch
Be involved as much as possible in his/her own treatment plan
Be informed of the treatment process and expectations prior to admittance
Be given advance notice to any pending discharge and reasons thereof.
Be assured that any information contained in his/her record will not be released to any outside agency(s) or individual(s) with the client's written authorization
Have reasonable access to a telephone
Communicate with whomever he/she chooses as long as such communication does not violate the Renaissance Ranch policy or court instructions
Be fully informed of his/her legal, medical, and clinical status
Examine his/her file to the extent permitted by Renaissance Ranch policy and with a Counselor present
Receive equal treatment and opportunity regardless of race, color, creed, religion, handicap , disability, etc.
Voice grievances directly to management, counselors or other Renaissance Ranch without fear of reprisal
Be given a copy of his/her rights if requested
Be given reasons of involuntary termination, an opportunity to state their view and the criteria for readmission into the program
Be protected from harm or acts of violence
Be assured that the rights of smokers and non-smokers comply with the Clean Air Act.
Clients are encouraged to report any offenses to these rights to the Executive Directory
We are wanting to measure the quality of service that we have provided here at Renaissance Ranch to our patients. This particular information is important to help improve the services we offer to you and the recovery community.
This information will be collected within 30 days of you having been discharged or graduating from Renaissance Ranch. We would appreciate your cooperation in improving our services. Your opinion matters to us. You are not required to participate in this survey and can withdraw from this survey at anytime. You will not be denied from receiving further services from Renaissance Ranch R such as After care or returning to the program if you feel the need.
Please be assured we care about your confidentiality, and by participating in this survey it will not be compromised in any way. If you have any questions concerning this survey, please fell free to speak with a staff member.
I give consent to be contacted after graduating or discharging from Renaissance Ranch within 30-days to participate in this followup survey. I know that I do not have to participate if I so choose not to. I also understand that any information I give after being discharged is still protected under the Federal Confidentiality Regulations (42 DFR part 8)
This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR part 2)
The Federal rule prohibits you of making any further disclosure of this information unless further disclosure is expressly permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute an alcohol or drug patient.
I herby consent to unrestricted Disclosure and Communication between Renaissance Ranch and:*
The Purpose and need for disclosure is to coordinate care for my treatment of:*
I understand this consent will remain in effect for (1) one year from the date of signing. I understand that all information given under this consent is protected under the Federal Confidentiality regulations (Title 42 CFR part 2 of the US code and HIPPA Act of 1996, 45 CFR parts 160 and 164, Privacy and Security regulations) and cannot be disclosed without my written consent unless otherwise provided for in this regulation.
I have read the above, and understand it, and hereby voluntarily give my consent to the above mentioned disclosure until the following date:*
Attend groups on time and be prepared with completed assignments.
Attend 4 meetings a week during IOP (90 days), Clients will complete the required 12 step work before stepping down to GOP (90 days). Client will then attend 2 meetings a week for GOP (90 days). The IOP & GOP groups on-site are included in this plan. We will not count 2 meetings in one day.
There will be attendance of official 12 step meetings. Informal meetings will not be counted unless there are prior arrangements with a counselor.
I will give at least a 4 hour notice to the staff if I am unable to attend groups. This will be considered an excused absence. Anything less than 4 hours of notice, will be considered an unexcused absence. (3) Three missed IOP groups or more that are unexcused absences can result in the dismissal of the participation from the program. (2) Two missed GOP or more unexcused absences in a month can result in a dismissal from the program.
I agree to make up any GOP missed groups by attending another day that I am not scheduled to attend.
Complete treatment work and assignments on time and come prepared to groups with material that is provided.
Wear appropriate attire which included:
Females: No shorts or short skirts. No low cut shirts or shirts that show the mid area. No swim suits or tank tops.
Males: NO tank tops
Comply with reasonable staff instructions.
No Smoking within 25 feet of any entrances to the building or its adjacent entrances. This includes the parking lot.
Not to engage in theft or illegal activity on or off the premises. This will result in immediate dismissal from the program.
DO NOT possess or consume alcohol, drugs or any other mood altering substances. This could result in dismissal from the program.
If you call in sick, you will come to the Renaissance Ranch facility to drug test on that day or bring an actual Doctors note on letterhead from the Dr. office in which you attended.
Clients are able to file a grievance if they feel they have been wronged in any way. Grievances must be in writing and will be addressed in writing with 3-5 business days.
Clients are not to verbally threaten or physically abuse other clients or family members. This type of behavior will result in immediate dismissal from the program.
I am willing and will be responsible cost wise for any outside testing due to urine analysis at the lab, upon request of the counselor or other staff members.
I have read & understand the requirements above & will abide by the rules.
I have a full understanding that I am being permitted to attend family groups at Renaissance Ranch during group hours. In this circumstance, I understand I will see and hear things that are discussed in the utmost confidence of the patients attending this program through Renaissance Ranch. I am therefore agreeing that I am bound by Utah stat law 42- CFR part 8 to not discuss whom I see or what I hear outside the clinic. I agree to keep all patient information confidential.
(Notice: This communication may contain protected health information, the release of which is restricted by federal law. Any information about a client or clients has been disclosed to you from records protected by federal confidentiality rules governing federally-assisted drug or alcohol abuse programs (42 CFR part 2) and the Heath Insurance Portability and Accountability Act of 1996 (HIPAA). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person whom it pertains or as otherwise permitted by 42 CFR part 2, and HIPAA. A general authorization is NOT sufficient for this purpose.)
Consent to Follow Up After Services
Program Rules and Conduct
Family Confidentiality Agreement