CONSENT FORM

Client Choice Form

DOB: MID#

I,, understand that NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER is a voluntary program and that my participation in the program is by:


I understand that there are a number of providers qualified to provide the same services offered by NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER and these providers are ready to provide behavioral health services to me.


After being offered the above choices I have selected NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER to provide this service.
No one has exerted pressure on me to select NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER and I am confident that this provider is best suited to meet my behavioral health needs.


I understand that if I find that NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER does not meet my needs, I may select another provider to replace NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER at any time.




Signature of Client/Guardian:

Printed Name of Client/Guardian: Date:

Signature Name of Witness (Intake Therapist):

Printed Name of Witness (Intake Therapist):


Client Information Face Sheet

Client Full Name: Also Known As:

Date of Birth: | Sex: MaleFemale

Martial Status: SingleMarriedDivorcedWidow

Record #:

Date Admitted: | Time Admitted:

ADMITTING AGE:

ADMITTING DIAGNOSIS:

CLIENT ADDRESS:

PHONE NUMBER:

ALLERGIES:

TB BOOSTER DATE:

CLIENT'S PLACE OF BIRTH:

LEGAL COUNTY OF RESIDENCE:

DATE OF GUARDIANSHIP ( WHERE APPLICABLE)

IS CLIENT INVOLVED WITH DHR? IF SO, PLEASE WRITE CASEWORKERS NAME, NUMBER & COUNTY:

CLIENT PHARMACY INFORMATION:

IS CLIENT INVOLVED WITH ANY OTHER PROGRAM? YesNo

MOTHER'S MAIDEN NAME:

FATHER'S NAME:

LEGAL STATUS:

NAME OF LEGAL GUARDIAN RELATIONSHIP:

LEGAL GUARDIANS ADDRESS & PHONE NUMBER

MEDICAID NUMBER:

OTHER INSURANCE (GROUP NAME)/ADDRESS:

EMERGENCY CONTACTS

1. NAME:

RELATIONSHIP:

ADDRESS OF FIRST EMERGENCY CONTACT:

TELEPHONE NUMBER:

WORK TELEPHONE NUMBER:

EMERGENCY TELEPHONE NUMBER:

2. NAME:

RELATIONSHIP:

ADDRESS OF FIRST EMERGENCY CONTACT:

TELEPHONE NUMBER:

WORK TELEPHONE NUMBER:

EMERGENCY TELEPHONE NUMBER:

3. NAME:

RELATIONSHIP:

ADDRESS OF FIRST EMERGENCY CONTACT:

TELEPHONE NUMBER:

WORK TELEPHONE NUMBER:

EMERGENCY TELEPHONE NUMBER:

PRIMARY PHYSICIAN:

ADDRESS:

PHONE NUMBER:

DATE DISCHARGED:

TIME DISCHARGED:

LAST CONTACT DATE:


Consent for Emergency Medical Treatment

(See next page for Non-Consent for Emergency Medical Treatment)
Client Name: Date of Birth:
Parent/Guardian:
Address:
Telephone:
Client’s Disability:
Physician’s Name:
Address:
Telephone:
Preferred Medical Facility:
Does client have any medical condition(s) requiring special precautions or treatments and any medications and dosage? Yes (please describe)No If you answered “Yes”, please describe:

In case of emergency, the undersigned authorizes NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, acting through the adult on its staff who has actual care, control, and possession of the child, to consent to medical, dental, and surgical treatment of the child when the undersigned cannot be contacted. The undersigned represents to NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, that he or she is the child’s parent and either (a) is not divorced form the other parent, or (b) is divorced from the other parent, but has been authorized by a written court order to give consent to medical and dental care and surgical treatment of the child. The undersigned will indemnify and hold NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, its officers, members, employees, and agents harmless if he or she is not empowered by law to give this consent.
The undersigned authorizes any licensed physician and/or medical facility to provide any medical/surgical care and/or hospitalization for the child, including anesthetic, which they determine necessary or advisable, pending receipt of a special consent from the undersigned.
No person can be accepted for services until this form has been completed by the parent/parents or guardian. If the person is of legal age (21), he or she may complete the form, if he or she is legally competent to do so. Although every effort will be made to avoid any accident, NO LIABILITY can be accepted by NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER.

I also understand that if NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, has to call the ambulance service for any reason, NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, is not responsible for payment for any charges occurred.
Yes, I would like to receive services from NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER,I understand NO LIABILITY can be accepted by NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, in the event of any accident that may occur.

Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:
Client/Parent Insurance Carrier:
Policy Number:


Non-Consent for Emergency Medical Treatment

(Please note that you will NOT need to complete this Non-Consent for Emergency Medical Treatment Form IF you have already completed and signed the Consent Form)
Client Name: Date of Birth:
Parent/Guardian:
Address:
Telephone:

I do not give my consent for emergency medical treatment/aid in the event of illness of injury during the process of receiving services from NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER,. In the event emergency is required, I authorize NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, or its representative to take the following action in my behalf
Please notify the following individual(s) in the event of an emergency:

NAME:

RELATIONSHIP:

ADDRESS OF FIRST EMERGENCY CONTACT:

TELEPHONE NUMBER:

WORK TELEPHONE NUMBER:

EMERGENCY TELEPHONE NUMBER:

NAME:

RELATIONSHIP:

ADDRESS OF FIRST EMERGENCY CONTACT:

TELEPHONE NUMBER:

WORK TELEPHONE NUMBER:

EMERGENCY TELEPHONE NUMBER:

No person can be accepted for services at NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, until either this form or the Consent for Emergency Medical Treatment form has been completed. If the person is of legal age (21), he/she may complete the form. If the person is not of legal age, the form must be completed by the parent(s) or guardian. Activities will be supervised, and although every effort will be made to avoid any accident, NO LIABILITY can be accepted by NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER.

Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:


Consent for Treatment

My consent is my permission for NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER to provide me with the services that I have agreed to. The services I am to receive may include assessment/evaluation, referral, and/or ongoing treatment.
My services will be identified for me in my Individual Resiliency Plan or Person-Centered Plan. This Plan will be written by me and others who are working with me. It will have my goals and objectives on it. It will outline the services that have been authorized for me. My Plan will be updated as necessary. I will be asked to review and sign each Plan when it is done. I will also be offered a copy of my Plan each time it is updated. I can ask questions about the risks and benefits of any treatments, procedures, and/or medications prescribed for me.
As part of providing Mental Health or Substance Abuse services to me, I understand that for NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER may use and disclose information about me on a regular basis. The reasons for these routine uses and disclosures are:

  • For payment of my services
  • To carry out the necessary steps of my treatment – including the communication between for NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER and my provider to coordinate my care
  • For NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER operations including:

  • Handling my records
  • Health oversight activities – with the Georgia Division of Mental Health, Developmental Disabilities, and Addictive 
Services , Federal oversight bodies, and/or National accrediting agencies to monitor, audit and evaluate the administration of for NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER. 
Other disclosures of information about me may be made if ordered by a court. Or made on an emergency basis if there is a significant risk that I may harm myself or someone else. Any other disclosures of information about me will require my permission. I will be asked to sign a form to authorize (or “OK”) the disclosure. 
My consent in this document is given freely. My services are voluntary – unless part of a court order for treatment. If I change my mind and do not want services, that is my choice. I can tell any for NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER staff member and/or my service provider that I do not want to continue. I may be asked to sign the back of this form to withdraw my consent. I acknowledge that for NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER may terminate my services for reasons like: I move out of the county, I am no longer eligible for services, or if I stop participating. I may be provided with either Advance or Adequate Notice of Termination to alert me that my services are being terminated. 
Please check if you agree with the following statements: 
This form was reviewed with me in a language I can understand. I got answers to my questions about my Consent for Treatment.

Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:

DOB: MID#

The Witness is responsible to assure that the authorizing party signing has full knowledge of what s/he is signing and is able to grant consent.
Consent for Treatment is withdrawn – see the back of this form.
CONSENT FOR TREATMENT
As of this date I withdraw my consent.
My reason(s) are:

Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:


ELECTRONIC MAIL/FAX CONSENT FORM

EMAIL ADDRESS:

FAX NUMBER:

TELEPHONE NUMBER:

WORK TELEPHONE NUMBER:

I, , request and authorize NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER Clinic to communicate with me (and other authorized healthcare providers involved in my care) about any aspect of my behavioral health and medical care by email/fax.
My signature below denotes that I have read the document, Patient Electronic Communications –fact Sheet, and accept the risk of loss of privacy of confidential medical information associated with email/fax communication. I understand that I need to discuss with my providers whether or not they agree to email as a method of communication. I also agree that NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER or its employee/managers/ contractors shall not be liable for any type of damage or liability arising from or associated with the loss of confidentiality due to email/fax communication. Further, since NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER does not operate or control any service on the Internet, I understand that it cannot and does not guarantee that the use of this means of communication will be free from
Technological difficulties including, but not limited to, loss of messages.
This authorization for communication by means of email/fax is valid until I notify you in writing that I no longer authorize the use of email/faxes to communicate information concerning my health care. I understand that information communicated by email/fax will be incorporated and retained in my legal medical record. NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER also retains the right to terminate email as a communication option if it becomes unduly burdensome or used inappropriately.
Any questions you many have about the appropriateness of email communication should be asked before signing.

Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:


Disclosure Form

NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER 
AUTHORIZATION FOR THE USE / DISCLOSURE / EXCHANGE OF CONFIDENTIAL / PROTECTED INFORMATION
CUSTOMER NAME:
PREVIOUS NAME:
DATE OF BIRTH:

I, ,hereby authorize NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER, INC. to use/disclose/exchange the following confidential/protected information to/with:

NAME OF PERSON OR ORGANIZATION:
ADDRESS CITY, STATE & ZIP CODE:
Format of the disclosure being authorized: Oral Written
The following information from my psychiatric/medical record(s) may be disclosed (must be completed):

Assessment(s)
Psychiatric Evaluation
Treatment Plan
Psychological Testing Results
Medication Management Results
Progress/Treatment Results
Admission/Discharge Information
Documentation/Therapist Notes

Any information NOT to be released: Purpose for disclosure:
Diagnostic Testing Results
Drug Usage/History
Treatment Attendance (SA) School Records (including IEPs) Other:
Other: Other:

Personal statements about this disclosure of confidential/protected information:
▪I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain Mental Health Services/treatment.
▪I understand that my primary clinician for mental health services will have access to my substance abuse treatment records in their role as coordinator of my care.
▪I understand that I will need to complete a separate authorization for each individual agency in order to release information about the following serious communicable diseases: HIV, AIDS, ARC, TB and Hepatitis.
▪I understand that I might be denied substance abuse treatment if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.
▪I understand that I may withdraw my authorization at any time. I understand also that such withdrawal of my authorization may not be effective to prevent disclosure of information previously authorized or to stop previous action that has been taken in reliance on this authorization.
▪I understand that, if the person or entity receiving this information is not covered by the Federal Privacy Regulations, such information may no longer be protected from further disclosure (unless it is also covered by the Substance Abuse Confidentiality Act - 42 CFR Part 2, further disclosure is prohibited).
▪I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR Parts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that records concerning mental health services I receive are protected under state and federal code.
▪My signature means that I have read this form and/or have had it read to me and explained in language I can understand. I know what information will be disclosed and give my voluntary consent to its release.
▪All the blank spaces have been filled in except for the spaces reserved for my signature, signature of witness, and dates. 

Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:
**THIS AUTHORIZATION WILL EXPIRE ONCE THE PURPOSE FOR THIS DISCLOSURE CEASES TO EXIST, BUT NO LATER THAN ONE YEAR FROM THE ORIGINAL DATE OF SIGNING UNLESS REVOKED PRIOR TO EXPIRATION.


CLIENT SERVICE FORM

SERVICE: CLIENT APPROVAL TO PARTICIPATE: INTAKE SPECIALIST INITIALS:
INDIVIDUAL COUNSELING (Therapist)
FAMILY COUNSELING (Therapist)
BEHAVIOR ASSESSMENT/TREATMENT PLAN UPDATE (every 6 months)
PSYCHOLOGICAL EVALUATION/TESTING (Psychologist)
MEDICATION ADMINISTRATION/MANAGEMENT ( Psychiatrist)
GENESIGHT TESTING(1X ONLY)
CLIENT RECEIVED A COPY OF THE NACFTC CONSUMER HANDBOOK

BY SIGNING THIS FORM, I AM STATING THAT I WOULD LIKE TO PARTICIPATE IN ALL SERVICES THAT HAVE A “X” BY THEM. IF I DON’T WANT COUNSELING AT THIS TIME, I AM AWARE THAT I CAN CONTACT THE CLINICAL DIRECTOR AT ANY TIME TO HAVE COUNSELING SERVICES PROVIDED.
Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:
BY SIGNING THIS, I AM STATING THAT I HAVE REVIEWED ALL SERVICES WITH THIS CLIENT/GUARDIAN.
INTAKE SPECIALIST SIGNATURE:
Date:


Confidentiality of Patient Records

The confidentiality of patient records maintained by NOAH’S ARK CHILD AND FAMILY TREATMENT CENTER is protected by Federal law and regulations. Generally, the program may not say to a person outside of program that a patient attends the program, or disclose any information unless:
The patient consents in writing
The disclosure is allowed by a court order; or
The disclosure is made to medical personnel in medical emergency or to qualified personnel for research, audit or program evaluation
Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported by appropriate authorities in accordance with Federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities (see 42 U.S.C. 290dd-3 and 42 U.S.C.290ee-3 for Federal laws and 42 CFR part 2 for Federal regulations).
NACFTC does utilize an electronic system and clients will utilize this system to capture signature for updating treatment documentation. NACFTC will capture the client’s/Guardian’s signature to use for signature purposes on on-going documentation that the client/Guardian agree’s with. This information will be housed within our electronic system and only used by the client when making updates to treatment documentation.
By signing this document, I understand and will abide by the above requirements of this confidentiality form.

Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:


Cancellation Policy:

Confirmation of Doctors Appointments:

(Please Initial) It is the policy of Noah’s Ark Child and Family Treatment Center (NACFTC) that all doctors’ appointments must be confirmed within 24 hours from appointment time and date. If you do not confirm your appointment 24 hours prior to the appointment, you will be taken off the schedule for that day and will need to reschedule the appointment for a later date. Failure to continue not to confirm appointments within a 24 hour period after 3 scheduled appointments will result in an immediate discharge from all services provided By NACFTC.

Cancellation/ No Show Policy for Doctor Appointment:

(Please Initial) We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another consumer from getting much needed treatment. Conversely, the situation may arise where another consumer fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment schedule. If an appointment is not cancelled at least 24 hours then it will count towards a No Show. It is the policy of Noah’s Ark Child and Family Treatment Center (NACFTC), if you have 3 no shows or fail to cancel your appointment 3 times within a 24 hour time period you will be automatically discharged from all services provided by NACFTC.

Scheduled Doctor Appointments:

(Please Initial) We understand that delays can happen however we must try to keep the other consumers and doctors on time. If a consumer is 15 minutes past their scheduled time, it is the policy of Noah’s Ark Child and Family Treatment Center (NACFTC) to reschedule the appointment.

Standby Appointments:

(Please Initial) It is the policy of Noah’s Ark Child and Family Treatment Center (NACFTC) that if a consumer is on their second cancellation/no show appointment, failure to confirm appointment, or late appointment that they may be placed on standby. Standby is your ability to be present in the office waiting on a space for the doctor to see you. This simply means that the administrator staff will give you a time slot for you to come into the office and wait to see if we have any “no show” appointments. If we have any “no show” appointments we will speak with the doctors about seeing you. Please note: that with standby you will be expected to be present in the office at your assigned time slot. Should you leave and/or become unable to stay during the full time of your assigned time slot you will not be seen, and will have to take the next available appointment. Failure to not show up to next available appointment will result in immediate discharge from all services provided By NACFTC.

Therapist Appointments:

(Please Initial) It is the policy of Noah’s Ark Child and Family Treatment Center (NACFTC) to provide quality counseling service to our consumers and their families through individual and family counseling. Due to a huge demand of counseling services we must make sure that all consumers and their families are complaint with all counseling qualifications. These qualifications are but not limited to: 6 month Behavior assessments, attending all schedule counseling sessions; with the limit of 3 reschedule, cancelled/no show, or failure to follow-up, and consistent parent participation in counseling from consumer’s parent and/or guardian. Failure to meet the qualification of completing a Behavioral Assessment every 6 months will cause cease in all services provided by NACFTC. Three reschedule, cancelled/no show, or failure to follow-up will result in discontinuation of therapeutic services and continuation of medication management services only.

By signing below, you acknowledge that you have read and understand the Cancellation Policy for
Noah’s Ark Child and Family Treatment Center as described above.

Signature of Parent/Parents or Guardian:
Date:
Signature of Client Over Age of 21:
Date:
NACFTC Staff Signature :
Date: