Homestead Program 14921 W Camdon Drive Casa Grande, AZ

Transcription

Homestead Program
14921 W Camdon Drive
Casa Grande, AZ 85222
Phone: (520) 876-5293
Fax:
(520) 876-5613
Homestead North Program
7345 N Hidden Hills Road
Flagstaff, AZ 86001
Phone: (928) 526-2383
Fax:
(926) 526-1071
To Our Referring Agency Partners:
Thank you for referring your client/member to the Homestead/Homestead North
Program. We’ve tried to make our intake packet materials as user-friendly and
streamlined as possible while adhering to the mandated rules and regulations that we
must follow.
While we would ideally like parents/guardians to accompany the child to the intake, we
understand that is not always possible. If you cannot arrange for the parent/guardian to
be present at our facility at intake, please note the list of items on our “Documents
Required at Admission” page that we must have before the client is transported to
Homestead/Homestead North.
We look forward to working with you and other members of the Child and Family Team
as we progress toward returning the child to his or her home community with greater
supports, skills and strengths in place.
Please don’t hesitate to contact me if there is anything I can do to assist you in making
this process go more smoothly, or at any other time I can be of assistance.
Sincerely,
Brad Waters
Homestead/Homestead North Program Director
Cell: (602) 370-7278
[email protected]
Community Provider of Enrichment Services
4825 N Sabino Canyon Road
2403 W Huntington Dr., Suite 100
954 Highway 92
Tucson, Arizona 85750
Tempe, Arizona 85282
Bisbee, Arizona 85603
520/884/7954
602/431/9511
520/432/5453
520/884/0383 Fax
602-431/9538 Fax
520/432/2105 Fax
www.cpes.com
Homestead Client Information Sheet
Emergency Contact and Medical Information for a Child
Child’s Name
(Print)
DOB
M
F
SSN#
Sex
Provider:
NARBHA / Cenpatico (circle one)
Provider
ID#
Guardian Name
AHCCCS
ID#
Guardian Address:
Case Manager Name
Guardian Phone:
Physician Name
Referring Agency
Name
Date of Last Visit:
Address:
Phone
(
)
Psychiatrist
/Therapist Name
Phone
(
)
Date of Last Visit
Phone
(
)
Fax
(
)
W HAT QUESTION DO Y OU W ANT THE PSYCHOLOGICAL
EVALUATION T O ANSWER?
Primary Discharge Plan
Secondary Discharge Plan
PRIMARY EMERGENCY CONTACT
Name:
School, Employer or Day Program:
Relationship:
Address:
Address:
Home Phone
([
])
Work Phone
([
])
ALLERGIES (FOOD, M ED, ETC.)/SPECIAL HEALTH
CONSIDERATIONS :
Phone
Contact
Name
The average stay for a client in the Homestead Program is 2-4
weeks, and thus it is the responsibility of the case manager to
relay any and all homework assignments via fax or snail mail to
our site.
CHILD M AY BE RELEASED T O T HE FOLLOWING INDIVIDUALS UPON DISCHARGE
I authorize
DESIGNEE NAME:
Parent/Guardian Print & Sign
(child name) to be released to the following individuals upon discharge:
PHONE
([
])
DATE
CPES Homestead Intake Packet
1
Admit Requirements
Documentation you are required to
obtain from the current treatment
facility, case manager, guardian or
client.
Documentation included in the
intake packet
We must have the following documents reviewed and signed (by the parent/guardian & licensed
behavioral health personnel where noted) and sent to us before the child is transported.
1. Client Information Sheet – Please be sure to write a response to the
question, “What question do you want the psychological to answer?”
2. List of agency phone numbers and addresses and other miscellaneous
information.
3. General Consent and Authorization to Treatment
4. Informed Consent to Treatment
5. Authorization to Release Information
6. List of Client Rights
7. Homestead Grievance Policy and Procedure
8. Homestead Privacy Practices Guidelines
9. HIPPA Acknowledgement.
10. House Rules
11. The PRN Medication Form signed by the prescribing physician.
12. Informed Consent for Psychotropic Medication Treatment of Minor
13. Minors’ Consent to Participate in Telemedicine Care and Authorization
for Release of Information
 ITP (INTENT TO PAY ) LETTER WITH AUTHORIZATION CODE - NARBHA
 A copy of the client’s most recent comprehensive CORE ASSESSMENT
(SIGNATURE PAGE-SIGNED BY SOMEONE LICENSED BY THE STATE WITH AN L IN
THEIR CREDENTIALS , PART A, B, C,D , E AND DEMOGRAPHICS )

A copy of the client’s PHYSICAL EXAM (dated within 7 days of intake)
PLEASE WAIT UNTIL INTAKE HAS BEEN SCHEDULED

A copy of the client’s skin test for tuberculosis (TB) indicating a
negative reading. (DATED WITHIN 7 DAYS OF INTAKE !)
PLEASE WAIT UNTIL INTAKE HAS BEEN SCHEDULED
A copy of the client’s most recent INSURANCE CARDS , including AHCCCS.
A current copy of CRISIS/WRAP PLAN from referring agency.
 A list of the client’s MEDICAL RESTRICTIONS , ALLERGIES AND/OR SPECIAL


DIETARY NEEDS .

BEHAVIORAL HEALTH SERVICE PLAN with Homestead Program and CCS
listed as providing services.



Strengths Needs and Cultural Discovery Assessment. (SNCD)
A copy of all past psychological and/or psychiatric evaluations.
REASON for referral.
 AT LEAST 30 DAY SUPPLY OF EACH PRESCRIBED MEDICATION IS
REQUIRED TO BE ON THEIR PERSION AT TIME OF ADMIT.
Thank you in advance for your cooperation in providing these items. Once all documentation is received a determination will
be made in the best interest of the client and the resources available at our facility.
These documents and materials will be reviewed with parents/guardians at the time the child is admitted to the facility.
Again, please note that we will not be able to make any exceptions, all documentation must be
received prior to admit due to OBHL Rules and Regulations .
Agency Phone Numbers, Addresses and Miscellaneous Information
AGENCY NAME
ADDRESS
PHONE
Homestead Program
14921 W. Camdon Dr. Casa Grande, AZ. 85222
520 876-5293
Homestead North Program
7345 N Hidden Hills Rd, Flagstaff, AZ 86001
928-526-2383
Div. of Behavioral Health Services
150 N 18th Avenue, 2nd Floor, Phoenix, AZ 85007
602-364-4558
Office of Behavioral Health Licensure
150 N 18th Avenue, #410, Phoenix, AZ 85007
602-364-2595
Arizona DES Child Protective Services
P.O.Box 44240, Phoenix, AZ 85064-4240
888-767-2445
Cenpatico
1501 W Fountainhead Parkway, Tempe, AZ85282
866-495-6738
NARBHA
1300 S Yale, Flagstaff, AZ 86001
928-774-7128
Client Fees
Homestead does not charge clients fees since all services provided at Homestead are covered
through a contract between Homestead and the client’s Regional Behavioral Health Provider.
Refund Policy and Procedure
Since Homestead does not accept fees for clients we have no policy governing refunds of client fees.
Treatment Environment
Homestead is licensed as an unlocked facility.
Dress Code
We encourage youth to express themselves appropriately through dress and personal appearance
but do enforce the following guidelines for dress while at Homestead:

Clothes endorsing drugs or drug paraphernalia, alcohol, sex or violence are prohibited.

Gang or gang affiliated colors or articles of clothing, including bandanas, are prohibited

Mid drifts, skull caps or undergarments must be covered by outer garments.

Proper sleep attire (pajamas, night gowns, t-shirts and shorts, etc) is required.

Shoes must be worn at all times

Clients are asked not to borrow or give clothing or personal hygiene items to one another

Please do not bring jewelry to the facility. In instances where jewelry is brought it will be
secured and returned to the client upon discharge

If articles of clothing not specified in this dress code are, in the judgment of Homestead
Management, inappropriate, they will be secured and returned to the client’s guardian at
discharge.
Client Name
_______
______________________________________
Signature of Parent/Guardian
___________________
Date Reviewed
Homestead Program
GENERAL CONSENT AND AUTHORIZATION
I consent to the following treatment and authorizations. My consent is valid from the date the client is admitted through
the day the client is discharged. (Please be sure to check all boxes for which you give consent/authorization)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Necessary emergency treatment
Routine Medical Care
Emergency Dental Care
Use of sedation/restraint when prescribed by a physician for medical/dental use
Necessary educational, vocational, and therapeutic evaluation/assessments
Participation in routine recreational/leisure activities
Administration of over the counter medications and ongoing medications
RELEASE OF THE FOLLOWING INFORMATION:
Yes
No
Medical records
Yes
No
Educational
Yes
No
Social
Yes
No
Psychological
Yes
No
Financial
Yes
No
Other
For those categories marked "no", my signature is required prior to the occurrence of such events or the release of any
information.
The preceding has been explained to me and I certify that I understand it fully. I also understand that my consent may
be withdrawn at any time by my written notification to this agency.
Client Name (please print)
Date of Admission
Signature of Parent or Legal Guardian
Date Reviewed and Signed
CPES | Homestead Intake
3
Homestead Program
INFORMED CONSENT FOR CARE & TREATMENT
1.
I, the undersigned, hereby grant permission to Homestead, a program of Community Provider of Enrichment
Services, Inc. (Hereinafter known as CPES) to employ routine treatment services as may be deemed necessary
or advisable for my diagnosis and treatment.
2.
I understand that there is no guarantee that these treatment services will prove beneficial to me.
3.
I have been advised that should medications be prescribed or administered, that such medications may or may
not be effective and, in a small number of situations, I may have an adverse reaction to such medication. Any
medication issues will be discussed with me prior to prescription or administration, or changes.
4.
Additionally, the following has been specifically explained to me:

The specific treatment being proposed;

The intended outcome;

The nature and procedures of the proposed treatment;

Any risks and side effects of the proposed treatment, including any risks of not proceeding with the
proposed treatment; and,

That consent is voluntary (unless under court ordered treatment) and such consent may be withdrawn or
withheld at any time.
5.
Even though all information gathered in the course of my relationship with the CPES Homestead program is
confidential, this confidentiality is not absolute. In the cases of medical emergency, child abuse or neglect,
court order, or where otherwise legally required, essential information may be released.
6.
I agree to collaborate in the treatment planning process to the best of my ability.
7.
Services will be provided within the limitations of funding.
8.
Services are made available regardless of race, national origin, religion, gender, sexual orientation, age,
disability, marital status, diagnosis, or source of payment.
9.
I understand that at some time, it may be in the best interest of me, or CPES, for me to obtain care elsewhere. In
all cases of referral elsewhere, CPES will make every effort to facilitate continuity of care.
_________________________________________________
CLIENT NAME (PRINTED)
_________________________________________________
PARENT/GUARDIAN SIGNATURE
____________________________
DATE REVIEWED
COMMUNITY PROVIDER OF ENRICHMENT SERVICES, INC.
Authorization and Consent to Release/Receive/Exchange Clinical Information
(R9-20-211.B)
Date of Birth:
(First, Middle, Last)
Name:
Address:
City:
State:
Zip:
I HEREBY AUTHORIZE:
Name: Community Provider of Enrichment Services, Inc.
Licensed Address:
Site/Setting:
City:
State:
Zip:
To release, receive, and/or exchange the information described below and contained within my Clinical Records by phone, fax, email or other written means.
To/with:
(A separate Authorization and Consent to Release/Receive/Exchange Clinical Information form must be completed for each entity, individual, or
agency).
Provider Name
Other
Hospital (specify)
Other
Medical Doctor (specify)
Other
Family (specify)
Other
The purpose of the disclosure is: Progress towards treatment goals and /or compliance with service site rules.
1. The specific information and the extent of that information that I wish released is:
Psycho-Social Assessment
Diagnosis
Ongoing communication during:
Psycho-Social History
Test Results
Residential Placement or Services Provided
Psychiatric Evaluation
School Records
Service/Treatment Plan
Medical Information
Medical History
Outpatient Services
Other:
2. Records of the following specific information:
3. Records of the Period from
to
4. Records of treatment for chemical dependency issues:
Signature:
Yes
No
Date:
5. Records of testing and/or treatment for AIDS and AIDS related disease:
Signature:
Yes
No
Date:
I understand that my records are protected under State and Federal Confidentiality Regulations and cannot be disclosed under most circumstances
without my written consent. I certify that this consent has been given freely and voluntarily. I understand that services are not contingent upon my
consent for release of information made in good faith. I understand that this authorization will expire on the date determined below, immediately upon
my revocation, or upon discharge from the current setting. I understand revocation of my authorization to release information must be requested in
writing.
________
Staff Member Printed First & Last Name/Title/ Credentials
Staff Member Signature /Date
Signature of client
________
Date
If client is unable to sign, give reason
Other (First & Last Name)
__________
Date
If other, relationship to client: Guardian, etc.
______________
Expiration Date
Rev 1/11/13
CPES
RIGHTS, AGREEMENT, NOTICES, and CONSENT SIGNATURE PAGE
CLIENT RIGHTS:
I have received a copy of the “CLIENT RIGHTS” policy
Yes
No.
I accepted
or declined
opportunity to have the rights explained to me. I understand that I may file a grievance if I believe that any of my
Client Rights, or the rights of my child, ward, or person under my guardianship have been violated.
Signature of Client or Legally responsible party
Date
GRIEVANCE/COMPLAINTS:
I have received a copy of the “GRIEVANCE/COMPLAINTS” policy.
Yes
No. I accepted
or declined
opportunity to have the policy explained to me. I understand and agree to the terms of the policy.
the
the
Date
RIGHTS OF PERSONS WHO HAVE BEEN DEEMED SMI:
I have received a copy of the forms “RIGHTS OF PERSONS WHO HAVE BEEN DEEMED SMI” and “NOTICE OF
DISCRIMINIATION PROHIBITED FOR PERSONS WHO HAVE BEEN DEEMED SMI”
Yes
No. I
accepted
or declined
the opportunity to have the rights described on these documents explained to me.
I understand how to obtain further information about the rights described in this document.
Date
HIPPAA NOTICE:
I have received a copy of the “HIPAA NOTICE OF PRIVACY PRACTICES” form
Yes
No. I accepted
declined
the opportunity to have the rights under HIPAA explained to me. I understand how to file a complaint if I
believe my privacy rights or the privacy rights of my child, ward, or person under my guardianship have been violated.
Date
Employee / witness signature
Date
Rev Jan-13
or
CPES BH POLICY AND PROCEDURE MANUAL
POLICY TITLE:
5.03 Client Rights
RULE NUMBER:
R9-20-203(C)
MH 209
MH 211
PURPOSE:
To ensure that CPES staff and clients are aware of client rights.
POLICY STATEMENT:
CPES will adhere to all client rights as stipulated by various government agencies.
PROCEDURES:
A. All CPES clients will be given a copy of the following statement regarding rights upon
admission, and will acknowledge receipt of these rights via signature. If the
consumer is enrolled by the Department of Behavioral Health Services or a local
Tribal/Regional Behavioral Health Authority (T/RBHA) as an individual who is
seriously mentally ill, the rights are contained in 9 AAC 21. A consumer who does
not speak English or who has a physical or other disability is to be assisted in
becoming aware of consumer rights:
1. to be treated with dignity, respect, and consideration;
2. not to be discriminated against based on race, national origin, religion, gender,
sexual orientation, age, disability, marital status, diagnosis, or source of
payment.
3. To receive treatment that:
a. supports and respects the client's individuality, choices, strengths, and
abilities;
b. supports the client's personal liberty and only restricts the client's personal
liberty according to a court order; by the client's general consent; or as
permitted in this Chapter; and
c. is provided in the least restrictive environment that meets the client's
treatment needs.
4. not to be prevented or impeded from exercising the client's civil rights unless the
client has been adjudicated incompetent or a court of competent jurisdiction has
found that the client is unable to exercise a specific right or category of rights.
5. To submit grievances to agency staff members and complaints to outside entities
and other individuals without constraint or retaliation.
6. To have grievances considered by a licensee in a fair, timely, and impartial
manner.
7. To seek, speak to, and be assisted by legal counsel of the client's choice, at the
client's expense;
8. To receive assistance from a family member, designated representative, or other
individual in understanding, protecting, or exercising the client's rights.
DATE ORIGINATED: 8/31/12
LAST REVISION DATE:
Page 1 of 14
REVISION #
POLICY TITLE:
5.03 Client Rights
RULE NUMBER:
R9-20-203(C)
MH 209
MH 211
9. If enrolled by the Department or a Regional Behavioral Health Authority as an
individual who is seriously mentally ill, to receive assistance from human rights
advocates provided by the Department or the Department's designee in
understanding, protecting, or exercising the client's rights.
10. To have the client's information and records kept confidential and released only
as permitted under R9-20-211(A)(3) and (B).
11. To privacy in treatment, including the right not to be fingerprinted,
photographed, or recorded without general consent, except:
a. for photographing for identification and administrative purposes, as provided
by A.R.S. § 36-507(2);
b. for a client receiving treatment according to A.R.S. Title 36, Chapter 37;
c. for video recordings used for security purposes that are maintained only on a
temporary basis; or
d. as provided in R9-20-602(A)(5).
12. To review, upon written request, the client's own record during the agency's
hours of operation or at a time agreed upon by the clinical director, except as
described in R9-20-211(A)(6).
13. To review the following at the agency or at the Department:
a. this Chapter;
b. the report of the most recent inspection of the premises conducted by the
Department;
c. a plan of correction in effect as required by the Department;
d. if the licensee has submitted a report of inspection by a nationally recognized
accreditation agency in lieu of having an inspection conducted by the
Department, the most recent report of inspection conducted by the nationally
recognized accreditation agency; and
e. if the licensee has submitted a report of inspection by a nationally recognized
accreditation agency in lieu of having an inspection conducted by the
Department, a plan of correction in effect as required by the nationally
recognized accreditation agency.
14. To be informed of all fees that the client is required to pay and of the agency's
refund policies and procedures before receiving a behavioral health service,
except for a behavioral health service provided to a client experiencing a crisis
situation.
15. To receive a verbal explanation of the client's condition and a proposed
treatment, including the intended outcome, the nature of the proposed
treatment, procedures involved in the proposed treatment, risks or side effects
from the proposed treatment, and alternatives to the proposed treatment;
LAST REVISION DATE:
Page 2 of 14
REVISION #
POLICY TITLE:
5.03 Client Rights
RULE NUMBER:
R9-20-203(C)
MH 209
MH 211
16. To be offered or referred for the treatment specified in the client's treatment
plan.
17. To receive a referral to another agency if the agency is unable to provide a
behavioral health service that the client requests or that is indicated in the
client's treatment plan.
18. To give general consent and, if applicable, informed consent to treatment,
refuse treatment or withdraw general or informed consent to treatment, unless
the treatment is ordered by a court according to A.R.S. Title 36, Chapter 5, is
necessary to save the client's life or physical health, or is provided according to
A.R.S. § 36-512.
19. To be free from:
a. abuse;
b. neglect;
c. exploitation;
d. coercion;
e. manipulation;
f. retaliation for submitting a complaint to the Department or another entity;
g. discharge or transfer, or threat of discharge or transfer, for reasons unrelated
to the client's treatment needs, except as established in a fee agreement
signed by the client or the client's parent, guardian, custodian, or agent;
h. treatment that involves the denial of:
i. food,
ii. the opportunity to sleep, or
iii. the opportunity to use the toilet; and
iv. restraint or seclusion, of any form, used as a means of coercion, discipline,
convenience, or retaliation.
20. To participate or, if applicable, to have the client's parent, guardian, custodian or
agent participate in treatment decisions and in the development and periodic
review and revision of the client's written treatment plan.
21. To control the client's own finances except as provided by A.R.S. § 36-507(5);
22. To participate or refuse to participate in religious activities.
23. To refuse to perform labor for an agency, except for housekeeping activities and
activities to maintain health and personal hygiene.
24. To be compensated according to state and federal law for labor that primarily
benefits the agency and that is not part of the client's treatment plan.
25. To participate or refuse to participate in research or experimental treatment.
LAST REVISION DATE:
Page 3 of 14
REVISION #
POLICY TITLE:
5.03 Client Rights
RULE NUMBER:
R9-20-203(C)
MH 209
MH 211
26. To give informed consent in writing, refuse to give informed consent, or
withdraw informed consent to participate in research or in treatment that is not
a professionally recognized treatment.
27. To refuse to acknowledge gratitude to the agency through written statements,
other media, or speaking engagements at public gatherings.
28. To receive behavioral health services in a smoke-free facility, although smoking
may be permitted outside the facility.
29. If receiving treatment in a residential agency, an inpatient treatment program,
a Level 4 transitional agency, or a domestic violence shelter:
a. If assigned to share a bedroom, to be assigned according to R9-20-405(F)
and, if applicable, R9-20-404(A)(4)(a).
b. To associate with individuals of the client's choice, receive visitors, and make
telephone calls during the hours established by the licensee and
conspicuously posted in the facility, unless:
i. the medical director or clinical director determines and documents a
specific treatment purpose that justifies restricting this right;
ii. the client is informed of the reason why this right is being restricted; and
iii. the client is informed of the client's right to file a grievance and the
procedure for filing a grievance;
c. To privacy in correspondence, communication, visitation, financial affairs,
and personal hygiene, unless:
i. the medical director or clinical director determines and documents a
ii. the client is informed of the reason why this right is being restricted; and
iii. the client is informed of the client's right to file a grievance and the
procedure for filing a grievance;
d. To send and receive uncensored and unopened mail, unless restricted by
court order or unless:
i. The medical director or clinical director determines and documents a
ii. The client is informed of the reason why this right is being restricted; and
iii. The client is informed of the client's right to file a grievance and the
procedure for filing a grievance.
e. To maintain, display, and use personal belongings, including clothing, unless
restricted by court order or according to A.R.S. § 36-507(5) and as
documented in the client record.
f. To be provided storage space, capable of being locked, on the premises
while the client receives treatment.
LAST REVISION DATE:
Page 4 of 14
REVISION #
POLICY TITLE:
5.03 Client Rights
RULE NUMBER:
R9-20-203(C)
MH 209
MH 211
g. To be provided meals to meet the client's nutritional needs, with consideration
for client preferences.
h. To be assisted in obtaining clean, seasonably appropriate clothing that is in
good repair and selected and owned by the client.
i. To be provided access to medical services, including family planning, to
maintain the client's health, safety, or welfare.
j. To have opportunities for social contact and daily social, recreational, or
rehabilitative activities.
k. To be informed of the requirements necessary for the client's discharge or
transfer to a less restrictive physical environment.
l. To receive, at the time of discharge or transfer, recommendations for
treatment upon discharge.
B. If you have a serious or chronic mental illness, you have legal rights under federal
and state law. These rights include:
1. the right to appropriate mental health services based on your individual needs;
2. the right to participate in all phases of your mental health treatment, including
Individual Service Plan (ISP) meetings;
3. the right to a discharge plan upon discharge from a hospital;
4. the right to consent to or refuse treatment (except in an emergency or by court
order);
5. the right to treatment in the least restrictive setting;
6. the right to freedom from unnecessary seclusion or restraint;
7. the right not to be physically, sexually, or verbally abused;
8. the right to privacy (mail, visits, telephone conversations);
9. the right to file an appeal or grievance when you disagree with the services you
receive or your rights are violated;
10. the right to choose a designated representative(s) to assist you in ISP meetings
and in filing grievances;
11. the right to a case manager to work with you in obtaining the services you need;
12. the right to a written ISP that sets forth the services you will receive;
13. the right to associate with others;
14. the right to confidentiality of your psychiatric records;
15. the right to obtain copies of your own psychiatric records (unless it would not be
in your best interests to have them);
16. the right to appeal a court-ordered involuntary commitment and to consult with
an attorney and to request judicial review of court-ordered commitment every 60
days;
17. the right not to be discriminated against in employment or housing.
LAST REVISION DATE:
Page 5 of 14
REVISION #
POLICY TITLE:
5.03 Client Rights
RULE NUMBER:
R9-20-203(C)
MH 209
MH 211
Notice of Discrimination Prohibited:
1. Persons undergoing evaluation or treatment pursuant to this Chapter shall
not be denied any civil right, including, but not limited to, the right to
dispose of property, sue and be sued, enter into contractual relationships
and vote. Court-ordered treatment or evaluation pursuant to the Chapter is
not a determination of legal incompetency, except to the extent provided in
A.R.S.§36-512.
2. A person who is or has been evaluated or treated in an agency for a mental
disorder shall not be discriminated against in any manner, including but not
limited to:
a. Seeking employment.
b. Resuming or continuing professional practice or previous occupation.
c. Obtaining or retaining housing.
d. Obtaining or retaining licenses or permits, including but not limited to,
motor vehicle licenses, motor vehicle operator’s and chauffeur’s licenses,
and professional or occupational licenses.
3. "Discrimination" for purposes of this Section means any denial of civil rights
on the grounds of hospitalization or outpatient care and treatment unrelated
to a person's present capacity to meet the standards applicable to all
persons. Applications for positions, licenses and housing shall contain no
requests for information which encourage such discrimination
4. Upon discharge from any treatment or evaluation agency, the patient shall
be given written notice of the provisions of this Section.
If you would like information about your rights, you may request a copy of the "Your
Rights in Arizona as an Individual with Serious Mental Illness" brochure or you may also
call the Arizona Department of Health Services, Office of Human Rights at 1-800-4212124.
RELEVANT PROTOCOLS, FORMS AND EXAMPLES:
See relevant protocols in the site's Protocol Manual; forms and examples on the
corporate drive at “K:\Master Forms\CPES\CPES-Clinical Services” as applicable.
Residential Services:
Protocols:
 N/A
Forms:
 Signature Sheet Rights and Notices
LAST REVISION DATE:
Page 6 of 14
REVISION #
POLICY TITLE:
5.03 Client Rights
RULE NUMBER:
R9-20-203(C)
MH 209
MH 211
 Client Rights and SMI Rights
Outpatient Services:
Protocols:
 N/A
Forms:
 Signature Sheet Rights and Notices
 Client Rights and SMI Rights
LAST REVISION DATE:
Page 7 of 14
REVISION #
CPES BH MANUAL DE NORMAS Y PROCEDIMIENTOS
TITULO DEL PROCEDIMIENTO:
5.03 Derechos del Cliente
REGLAMENTO NÚMERO:
R9-20-203(C)
MH 209
MH 211
PROPOSITO:
Asegurar que CPES y sus clientes estén consientes de cuales son los derechos de los
clientes.
ENUNCIACION DE LA NORMA:
CPES se adhiere a todos los derechos de los clientes según lo estipulado por las
diversas agencias gubernamentales.
PROCEDIMIENTOS:
A. Una vez que son ingresados, todos los clientes de CPES deberán de recibir una copia
de la siguiente declaración sobre sus derechos y confirmaran la recepción de este
documento mediante su firma. Si el consumidor fue inscrito por el Departamento de
Servicios de Salud Mental o una autoridad de salud mental tibutaria o regional
(T/RBHA) como una persona que posee una enfermedad mental seria, los derechos
están contenidos en 9 AAC 21. Un consumidor que no habla ingles o que tiene una
incapacidad física o de otra índole deberá ser asistido en ser informado de sus
derechos como consumidor los cuales incluyen:
1. a ser tratado con dignidad, respeto y consideración;
2. a no ser objeto de discriminación basándose en raza, nacionalidad de origen,
religión, sexo, orientación sexual, edad, incapacidad, estado civil, diagnostico o
fuente de pago.
3. a recibir un tratamiento que:
a. apoye y respete su individualidad como cliente, sus opciones, fortalezas y
habilidades;
b. apoye la libertad personal del cliente y solo la restrinja de acuerdo con una
orden judicial, mediante el consentimiento general del cliente o como es
permitido en el presente capitulo, y
c. se proporcione en el ambiente menos restrictivo que satisfaga las
necesidades de tratamiento del cliente.
4. a no ser prevenido o impedido de ejercitar sus derechos civiles como cliente al
menos que haya sido declarado incompetente por un juzgado de jurisdicción
competente que haya encontrado que el cliente no puede ejercitar un derecho
específico o categoría de derechos
5. A presentar quejas a los miembros del personal de la agencia y reclamaciones a
entidades externas y a otros individuos sin restricciones o represalias.
FECHA EN LA CUAL FUE ORIGINADO: 8/31/12
FECHA DE LA ULTIMA REVISION:
Pagina 8 of 14
# de REVISION
REGLAMENTO NÚMERO:
R9-20-203(C)
MH 209
MH 211
6. A que sus quejas sean examinadas por una autoridad competente de manera
justa, oportuna e imparcial.
7. A hablar y ser asistido por un abogado elegido por el cliente, a expensas del
cliente;
8. A recibir asistencia por parte de un familiar, representante designado u otro
individuo en el entendimiento, protección o ejercicio de los derechos del cliente.
9. Si ha sido inscrito por el Departamento o Autoridad Regional de Salud como un
individuo con una enfermedad mental seria, a recibir asistencia de parte de los
defensores de derechos humanos proporcionados por el Departamento o la
persona designada por el Departamento en la comprensión, protección y
ejercicio de los derechos del cliente.
10. A que la información y los archivos del cliente sean mantenidos confidenciales y
sean entregados exclusivamente como es establecido en R9-20-211(A)(3) y (B).
11. A la privacidad en su tratamiento, incluyendo el derecho a no tomarle sus
huellas, ser fotografiado o grabado sin un consentimiento general, excepto:
a. a ser fotografiado con fines de identificación y administrativos como lo
dispone A.R.S. § 36-507(2);
b. para que un cliente reciba tratamiento como lo establece A.R.S. Titulo 36,
Capitulo 37;
c. para grabaciones de video que sean usadas por propósitos de seguridad y
son mantenidas solo de manera temporal; o
d. como esta establecido en R9-20-602(A)(5).
12. A examinar, mediante previa solicitud por escrito, los archivos propios del cliente
durante las horas hábiles de la agencia o durante un horario acordado con el
director clínico, excepto como esta descrito en R9-20-211(A)(6).
13. A revisar lo siguiente en la agencia o en el Departamento:
a. este Capitulo;
b. el reporte de la inspección mas reciente de las instalaciones conducida por el
Departamento;
c. un plan de corrección en efecto como se requiera por el Departamento;
d. si el titular ha presentado un informe de inspección por parte de una agencia
de acreditación reconocida a nivel nacional, en vez de tener una inspección
llevada a cabo por el Departamento, el informe más reciente de la inspección
realizada por la agencia de acreditación reconocida a nivel nacional, y
e. si el titular en vez de tener una inspección llevada a cabo por el
Departamento presenta un informe de inspección por parte de una agencia
acreditada reconocida a nivel nacional, un plan de corrección en efecto
como lo requiere la agencia de acreditación reconocida a nivel nacional
Pagina 9 of 14
# de REVISION
REGLAMENTO NÚMERO:
R9-20-203(C)
MH 209
MH 211
14. A ser informado de todas las cuotas que el cliente está obligado a pagar y de las
políticas y procedimientos de rembolso de la agencia antes de recibir un servicio
de salud mental, a excepción de servicios de salud mental proporcionados a un
cliente que experimenta una situación de crisis.
15. A recibir una explicación verbal de la condición del cliente y el tratamiento
propuesto, incluyendo el resultado esperado, la naturaleza del tratamiento
propuesto, los procedimientos implicados en el tratamiento propuesto, los
riesgos o efectos secundarios del tratamiento propuesto y las alternativas al
tratamiento propuesto;
16. A que se le ofrezca o sea referido para el tratamiento especificado en el plan de
tratamiento del cliente.
17. A recibir una referencia a otra agencia si la agencia no puede ofrecer el servicio
de salud mental que el cliente solicite o que se indica en el plan de tratamiento
del cliente.
18. A dar un consentimiento general y, si procede, consentimiento informado del
tratamiento, a rechazar el tratamiento o retirar el consentimiento general o
informado del tratamiento, a menos que el tratamiento sea ordenado por un
tribunal de acuerdo con ARS Título 36, Capítulo 5, si es necesario para salvar la
vida del cliente o su salud física, o se proporciona de acuerdo con ARS § 36512.
19. A ser libre de:
a. abuso;
b. negligencia;
c. explotación;
d. coerción;
e. manipulación;
f. represalias por presentar una queja al Departamento u otra entidad;
g. a ser dado de alta o ser amenazado con ser dado de alta por razones que no
están relacionadas con las necesidades de tratamiento del cliente, excepto
con lo establecido en un acuerdo de pago firmado por el cliente, o el padre,
tutor, custodio o agente del cliente;
h. tratamientos que impliquen la negación de:
i. i. alimentos,
ii. la oportunidad de dormir, o
iii. la oportunidad de ir al baño, y
iv. la restricción o cualquier forma de reclusión usadas como medios de
coerción, disciplina, conveniencia o represalia.
20. De participar o, en su caso, al padre, tutor o agente del cliente de participar en
las decisiones terapéuticas y en el desarrollo y revisiones periódicas del plan
escrito de tratamiento del cliente.
Pagina 10 of 14
# de REVISION
REGLAMENTO NÚMERO:
R9-20-203(C)
MH 209
MH 211
21. Al control de las finanzas del propio cliente, salvo lo dispuesto por el ARS § 36507 (5);
22. A participar o negarse a participar en las actividades religiosas
23. De negarse a realizar labores para una agencia, excepto para las actividades de
limpieza y actividades para mantener la salud e higiene personal.
24. A ser indemnizado conforme a la ley estatal y federal por realizar labores que
principalmente beneficien a la agencia y que no forman parte del plan de
tratamiento del cliente.
25. A participar o negarse a participar en la investigación o el tratamiento
experimental.
26. A dar su consentimiento informado por escrito, a negarse a dar su
consentimiento informado, o a retirar su consentimiento informado para
participar en la investigación o un tratamiento que no se un tratamiento
profesional reconocido.
27. A negarse a expresar su gratitud a la agencia a través de declaraciones escritas,
otros medios de comunicación, o charlas en reuniones públicas.
28. A recibir servicios de salud mental en un centro libre de humo de fumadores,
aunque fumar puede ser permitido fuera de las instalaciones.
29. Si recibe tratamiento en una agencia residencial, un programa de tratamiento
para pacientes hospitalizados, una agencia de transición de nivel 4, o un refugio
de violencia doméstica:
a. Si es asignado a compartir una habitación, a ser asignado de acuerdo con
R9-20-405 (F) y, en su caso, R9-20-404 (A) (4) (a).
b. A asociarse con individuos de la elección del cliente, recibir visitas y hacer
llamadas telefónicas durante las horas establecidas por el titular de la
agencia y las cuales deberán ser visiblemente publicadas en las
instalaciones, a menos que:
i.
el director médico o el director clínico determine y documente un
propósito especifico del tratamiento que justifica la restricción de este
derecho;
ii. el cliente es informado de la razón por la cual se restringe este
derecho, y
iii.
se informa al cliente del derecho que tiene a presentar una queja
formal y cual es el procedimiento para presentar una queja;
c. A la privacidad en la correspondencia, las comunicaciones, visitas, asuntos
financieros, e higiene personal, a menos que:
i.
derecho;
derecho, y
Pagina 11 of 14
# de REVISION
REGLAMENTO NÚMERO:
R9-20-203(C)
MH 209
MH 211
iii.
d. A enviar y recibir correo sin censura y sin que este sea abierto, a no ser que
este restringido por una orden judicial o a menos que:
i.
derecho;
derecho, y
iii.
e. A mantener, mostrar y utilizar artículos personales, incluyendo ropa, a
menos que este restringido por una orden judicial o de acuerdo con ARS §
36-507 (5) y como se documenta en el expediente del cliente.
f. A que durante el tiempo que el cliente recibe el tratamiento se le
proporcione un espacio que pueda ser cerrado para almacenamiento de
sus pertenencias dentro de las instalaciones.
g. A que se le proporcionen alimentos para satisfacer las necesidades
nutricionales de cada cliente, teniendo en consideración las preferencias
del cliente.
h. A recibir asistencia para obtener ropa limpia, apropiada a la estación, que
se encuentre en buenas condiciones y que sea selección y propiedad del
cliente.
i. A que se le proporcione acceso a servicios médicos, incluyendo la
planificación familiar, para mantener la salud del cliente, su seguridad y su
bienestar.
j. A tener oportunidades de contacto social y actividades sociales cotidianas,
recreativas o de rehabilitación.
k. A ser informado de los requisitos necesarios para ser dado alta o para
transferirlo a un ambiente de menor restricción física.
l. A recibir, en el momento de ser dado de alta o transferido, las
recomendaciones necesarias para continuar con el tratamiento posterior.
B. Si usted tiene una enfermedad mental grave o crónica, usted tiene derechos legales
bajo la ley federal y estatal. Estos derechos incluyen:
1. el derecho a servicios adecuados de salud mental basados en sus necesidades
individuales;
2. el derecho a participar en todas las fases de su tratamiento de salud mental,
incluyendo las reuniones del Plan de Servicio Individual (ISP);
3. el derecho a un plan para ser dado del tratamiento una vez que haya sido dado
de alta de un hospital;
Pagina 12 of 14
# de REVISION
REGLAMENTO NÚMERO:
R9-20-203(C)
MH 209
MH 211
4. el derecho de aceptar o rechazar el tratamiento (excepto en caso de emergencia
o por orden judicial);
5. el derecho a recibir tratamiento en el ambiente menos restrictivo;
6. el derecho a ser libre de reclusión o restricciónes innecesarias;
7. el derecho a no ser abusado física, sexual o verbalmente;
8. el derecho a la privacidad (correo electrónico, visitas, conversaciones
telefónicas);
9. el derecho de presentar una apelación o queja cuando no está de acuerdo con
los servicios que recibe o sus derechos han sido violados;
10. el derecho a elegir un representante designado (s) para asistirle en las reuniones
de ISP y en la presentación de quejas;
11. el derecho a un administrador de casos para trabajar con usted para obtener los
servicios que necesita;
12. el derecho a un ISP por escrito que establece los servicios que recibirá;
13. el derecho de asociarse con otras personas;
14. el derecho a la confidencialidad de sus expedientes psiquiátricos;
15. el derecho a obtener copias de sus expedientes psiquiátricos (a menos que no
sea en su mejor interés el tenerlos);
16. el derecho de apelar una orden de la corte de compromiso involuntario, de
consultar con un abogado y de solicitar la revisión judicial del compromiso
ordenado por la corte cada 60 días;
17. el derecho a no ser objeto de discriminación en el empleo y la vivienda
Notificación de la Prohibición de Discriminación:
1. Las personas que se someten a evaluación o tratamiento de acuerdo con el
presente capítulo no podrán ser negadas de ningún derecho civil, incluyendo,
pero sin limitarse a, el derecho a disponer de bienes, demandar y ser
demandado, entrar en relaciones contractuales y votar. El ser ordenado por el
tribunal para recibir tratamiento o ser evaluado de conformidad con este Capítulo
no es una determinación de incompetencia legal, excepto en la medida prevista
en ARS § 36-512.
2. Una persona que sea o haya sido evaluado o tratado en una agencia debido a
un trastorno mental no serán objeto de discriminación en cualquier forma,
incluyendo pero no limitándose a:
a. Búsqueda de empleo.
b. Reasumir o continuar la práctica de una profesional u ocupación anterior.
c. La obtención o conservación de la vivienda.
d. Obtener o retener licencias o permisos, incluyendo pero no limitándose a,
licencias de vehículos de motor, licencia de operador de vehículos de motor,
licencias de chofer y licencias profesionales u ocupacionales.
Pagina 13 of 14
# de REVISION
REGLAMENTO NÚMERO:
R9-20-203(C)
MH 209
MH 211
3. La "discriminación" para los propósitos de esta sección significa cualquier
negativa de los derechos civiles en base en la hospitalización o tratamiento que
no este relacionado con la capacidad actual de la persona para cumplir con las
normas aplicables a todas las personas. Las solicitudes para posiciones,
licencias y vivienda no deberán contener solicitudes de información que
fomenten dicha discriminación
4. Después de ser dado de alta de cualquier tratamiento o agencia de evaluación,
el paciente deberá ser notificado por escrito de las disposiciones de esta sección
Si desea recibir información acerca de sus derechos, puede solicitar una copia del
folleto "Sus derechos en Arizona como una persona con una enfermedad mental grave"
o también puede llamar a la Oficina de Derechos Humanos del Departamento de
Servicios de Salud de Arizona, al 1-800 -421-2124.
PROTOCOLOS PERTINENTES, FORMAS Y EJEMPLOS:
Vea los protocolos, formas y ejemplos correspondientes en el manual del Protocolo del
sitio, en la unidad corporativa de " K:\Master Forms\CPES\CPES-Clinical Services”,
según corresponda.
Servicios Residenciales:
Protocolos:
 N/A
Formas:
 Hoja de Firmas de Derechos y Avisos
 Derechos del cliente y Derechos del Cliente con una Enfermedad Mental
Grave
Servicios para Pacientes Externos:
Protocolos:
 N/A
Formas:
 Hoja de Firmas de Derechos y Avisos
 Derechos del cliente y Derechos del Cliente con una Enfermedad Mental
Grave
Pagina 14 of 14
# de REVISION
POLICY TITLE:
10.02 Grievances and Complaints
RULE NUMBER:
R9-20-201(B)(1)(c)
PURPOSE:
To communicate to CPES staff members and employees the steps required for a client
to file a grievance and/or complaint against CPES.
POLICY STATEMENT:
All clients receiving services through CPES have the right to use the process set forth in
this policy to appeal decisions regarding services applied for or received. The CPES
formal grievances policy follows procedures as set forth in local T/RBHA “ADHS Division
of Behavioral Health Services Notice of Grievance and Appeal Procedure.”
PROCEDURES:
A. Clients must be informed of this policy and of the policy on ‘Client Rights’ at the time
of initial intake. A person who wishes to express a concern or grievance regarding
CPES or its services may do so either through an informal or formal process and
both verbal and written grievances will be accepted. Grievances can be filed on
behalf of the CPES client, or if applicable by family members, significant others, or
client advocates.
B. CPES will not discharge or discriminate in any way against any client by whom or on
whose behalf a complaint has been submitted or who has participated in a complaint
investigation process.
C. Informal Process – The informal process at CPES must not exceed five (5) calendar
days and will begin with a discussion between the appropriate supervisory chain of
command and the client. At that time the matter should be documented by stating
the nature of the complaint and the desired outcome in writing and date-stamp the
complaint/grievance. If the problem cannot be resolved at this level, the next level
should be notified. If there is still no resolution, the appropriate Director level staff
will be called upon to help resolve the problem. At the end of the allotted time, if
there is no acceptable resolution, the informal complaint will automatically enter the
formal process. The client will be referred to the following section.
D. Formal Process – Grievances may be filed no later than one (1) year after the date
of the alleged rights violation or condition requiring investigation. ISP/Treatment
Plan appeals must be no later than 60 days of the decision or action being appealed.
Steps for the formal process are:
1. Request the Grievance Report Form from any administrative employee.
LAST REVISION DATE:
Page 1 of 3
REVISION #
POLICY TITLE:
RULE NUMBER:
R9-20-201(B)(1)(c)
2. Fill out the Grievance Report Form and submit it to the manager of the office or
residential setting.
3. The administrative employee will provide a copy for the client and submit the
original to the supervisor with a copy to appropriate CPES administrative staff.
4. The supervisor will contact the client within five (5) work days to gather more
information and work on resolution. The supervisor will document the results of
that initial contact on a Grievance Report Form and copy appropriate CPES
administrative staff.
5. If there was no resolution with the contact by the supervisor, administrative staff
will contact the client within ten (10) days.
6. Administrative staff will set an Initial Complaint Meeting for within fifteen (15)
days of receiving the Grievance Report Form. The Initial Complaint Meeting will
focus on reaching an optimal resolution to the client’s complaint.
7. The results of the Initial Complaint Meeting will be documented on the Grievance
Report Form. A copy will be given to the client and the original document will be
maintained at the administrative office.
8. If the Initial Complaint Meeting has satisfactorily resolved the client’s complaint,
the client should indicate his/her satisfaction on the Grievance Report Form.
9. In some cases the client may wish to by-pass the Initial Complaint Meeting
process and file their grievance directly with the DBHS Office of Grievance and
Appeals. In that case, they should indicate that intent on the Grievance Report
Form.
10. Any client may file a complaint at any time with:
ADHS/DBHS Office of Behavioral Health
150 N. 18th Ave., Ste. 410, Phoenix, AZ 85007
602-364-2595, 602-364-4801 (fax)
E. Appeal Process – A client who is dissatisfied with the resolution of his/her grievance
or appeal can appeal to the appropriate funding source, or the Arizona Department
of Health Services, Office of Grievances and Appeals, 150 N. 18th Avenue, Suite 210,
Phoenix AZ, 85007, (800) 421-2124.
F. Tracking – All documented grievances will be filed in a secure place, separate from
medical records, for a period of seven (7) years. The CPES Quality Improvement
Committee will track documented grievances and will notify the CEO as part of its
reporting procedure. Reports will be submitted to the local T/RBHA Quality
Assurance Office as required.
LAST REVISION DATE:
Page 2 of 3
REVISION #
POLICY TITLE:
RULE NUMBER:
R9-20-201(B)(1)(c)
RELEVANT PROTOCOLS, FORMS AND EXAMPLES:
See relevant protocols in the site's Protocol Manual; forms and examples on the
corporate drive at “K:\Master Forms\CPES\CPES-Clinical Services” as applicable.
Residential Services:
Protocols:
 N/A
Forms:
 Grievance Report Form
Outpatient Services:
Protocols:
 N/A
Forms:
 Grievance Report Form
LAST REVISION DATE:
Page 3 of 3
REVISION #
CPES Specialized Residential SMI Grievances
PM ATTACHMENT 5.5.1
ADHS/DBHS NOTICE OF SMI GRIEVANCE AND APPEAL PROCEDURE
It is the philosophy of the Arizona Department of Health Services, Division of Behavioral Health Services (ADHS/DBHS)
to provide state residents with timely access to appropriate, and effective behavioral health care. Services are provided
through the Regional Behavioral Health Authority (RBHA) or Tribal Regional Behavioral Health Authority (TRBHA).
Should you need to request an investigation, file an SMI grievance, or file an appeal, the following process is followed.
SMI GRIEVANCE/REQUEST FOR INVESTIGATION/
Any person may file an SMI grievance or request an investigation regarding any act or omission of ADHS/DBHS, the
Arizona State Hospital, the T/RBHA, or one of its providers, alleging that a rights violation or a condition requiring
investigation has occurred or currently exists. (Please note: allegations about the need for, or appropriateness of
behavioral health services should not be considered an SMI grievance, but should be addressed through the appeal
process described below.) The request may be verbal or written and must be initiated no later than one year after the date
of the alleged rights violation or condition requiring investigation. Forms for filing are available at ADHS/DBHS, the
Arizona State Hospital, the T/RBHAs, case management sites and at all provider sites.
All SMI grievances/requests for investigation must be filed with the appropriate RBHA. Allegation of rights violation by a
TRBHA or their providers or SMI grievances/requests for investigation related to physical or sexual abuse will be
addressed by ADHS/DBHS. SMI grievances/requests for investigations on such issues may be filed with the RBHA to be
forwarded to ADHS/DBHS or may be filed directly in writing with ADHS/DBHS at 150 North 18th Avenue, Suite 210,
Phoenix, Arizona 85007, or orally, by calling (602) 364-4591. Within 7 days of the date received, you will be sent an
acknowledgment letter and, if appropriate, an investigator will be assigned to research the matter. When a decision is
reached, you will receive a written response.
APPEAL
Any person, age 18 or older, his or her guardian, or designated representative, may file an appeal related to services
applied for, or services the person is receiving. Matters of appeal are generally related to a denial of services; disagreement
with the findings of an evaluation or assessment; any part of the Individual Service Plan; the Individual Treatment and
Discharge Plan; recommended services or actual services provided; barriers or unreasonable delay in accessing services
under Title XIX; and fee assessments. Appeals must be filed with the RBHA or ADHS/DBHS for the TRBHA and must be
initiated no later than 60 days after the decision or action being appealed. Appeal forms are available at ADHS/DBHS, the
T/RBHAs, case management sites and at all provider sites.
The RBHA or ADHS/DBHS (for TRBHA appeals) will attempt to resolve all appeals within seven days through an
informal process. If the problem cannot be resolved, the matter will be forwarded to ADHS/DBHS for further appeal. If
the RBHA will not accept your appeal or dismisses your appeal without consideration, you may request an Administrative
Review by ADHS/DBHS of that decision.
For SMI grievances/requests for investigation and appeals, to the greatest extent possible, please include:
1. Name of person filing the SMI grievance/request for investigation or appeal
2. Name of the person receiving services, if different.
3. Mailing address and phone number.
4. Date of issue being appealed or incident requiring investigation.
5. Brief description of issue or incident.
6. Resolution or solution desired.
For either process above, you may represent yourself, designate a representative, or use legal counsel. You may contact the
State Protection and Advocacy System, the Arizona Center for Disability Law 1-800-922-1447 in Tucson and 1-800-9272260 in Phoenix. You may also contact the Office of Human Rights at 1-800-421-2124 for assistance. If your complaint
relates to a licensed behavioral health agency, you may contact the Office of Behavioral Health Licensure, 150 N. 18th
Avenue, Phoenix, Arizona 85007, (602) 364-2595.
CPES
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 it carefully.
PRIVACY PROMISE
Community Provider of Enrichment Services, Inc. (CPES) knows how important it is to
keep your personal information confidential, and promises to follow strict federal and
state laws that require us to keep your personal information private.
HOW WE WILL USE YOUR PERSONAL INFORMATION
If you are being supported by CPES, we might use your personal information for such
activities as providing you with services, billing for services and conducting our regular
business known as health care operations.
If you have chosen a personal representative and have agreed to let your personal
representative obtain your personal information, we will provide the information to your
personal representative. If you have a guardian, we will provide the information to your
guardian.
Some examples of how we might use your information include:
 Treatment – We keep records of the care and services provided to within
CPES. For example, your Service Coordinator, Support Supervisor, Associate
Director, or any other important staff keeps notes on all contacts made in
coordinating and arranging for services. If you see a nurse or therapist who
works for CPES, they will keep records of any care you receive. CPES staff
may share your personal information while helping to develop your service plan.
If CPES staff want to share your personal information with anyone who is not
employed by CPES, you must give them your written permission first.
Some personal records, including confidential communications with a mental
health professional and substance abuse records may have additional
restrictions for use

Payment – We keep records that include payment information and
documentation of the services provided to you. Your information may be used
to obtain payment for your services from AHCCCS, insurance or other sources.
For example, we may disclose personal information about the services provided
to you to confirm your eligibility for AHCCCS and to obtain payment from
AHCCCS. CPES may use your personal information to determine the amount
and type of AHCCCS services you need and send this information to the proper
state department.
Revised 07/16/07

Health Care Operations – We use personal information to improve the quality of
care, train staff, manage costs, conduct required business duties and make
plans to better serve you and other individuals supported by CPES. For
example, we may use your personal information to evaluate the quality of
treatment and services provided by our service staff.
OTHER SERVICES WE PROVIDE
We may also use your personal information to:









Determine if you are eligible for CPES services
Recommend service alternatives and other possible benefits
Let you know about other service providers who may be able to help you
Remind you of an appointment, unless you let CPES staff know that you don’t
wish to be reminded
Allow CPES to review direct service contracts
Allow local, state and federal agencies to monitor your services
Investigate any incidents affecting your health and safety, to report these kinds
of incidents and to take steps to protect your health and safety
Allow CPES to prepare reports required by the Division of Developmental
Disabilities
Contact you for assistance in passing levies, unless you notify CPES that you
don’t wish to be contacted for these purposes
SHARING YOUR PERSONAL INFORMATION
There are limited situations when we are permitted or required to disclose personal
information without your signed authorization. These situations are:











To protect victims of abuse, neglect or domestic violence
To reduce or prevent a serious threat to public health and safety
For health oversight activities such as investigations, audits and inspections
For lawsuits and similar proceedings
For public health purposes, such as reporting communicable diseases, workrelated illnesses or other diseases and injuries, as permitted by law; reporting
births and deaths and reporting reactions to drugs and problems with
medical devices
When required by law
When requested by law enforcement, as required by law or court order
To coroners, medical examiners and funeral directors
For organ and tissue donation
For Worker’s Compensation or other similar programs, if you are injured at work
and are covered by Worker’s Compensation or other similar programs
For specialized government functions, such as intelligence and national security
All other uses and disclosures not described in this notice require your signed
authorization. You may revoke your authorization at any time with a written statement.
Revised 07/16/07
CPES’ PRIVACY RESPONSIBILITES
CPES is required by law to:



Maintain the privacy of your personal information
Provide this notice that describes the ways we may use and share your
personal information
Follow the terms of the notice currently in effect
We reserve the right to make changes to this notice at any time and make the new
privacy practices for all information we maintain. Current notices will be posted in all
CPES facilities and on the CPES website. You may also request a copy of any notice
from the CPES Privacy Officer.
YOUR INDIVIDUAL RIGHTS
You have the right to:






Request restrictions on how we use and share your personal information.
CPES will consider all requests for restrictions carefully, but is not required to
agree to any restriction.*
Request that we use a specific telephone number or address to communicate
with you
Inspect and copy your personal information, including service, medical and
billing records. Fees may apply.*
Request corrections or additions to your personal information. You must give
the reasons for wanting the change.*
Request an accounting of certain disclosures of your personal information
made by us. Your request must state the period of time desired for the
accounting, which must be within the six years prior to your request. The first
accounting is free, but a fee will apply if more than one request is made in a 12
month period.*
Request a paper copy of this notice even if you agree to receive it electronically
*Requests marked with a star (*) must be made in writing. Contact the CPES Privacy
Officer for the appropriate form for your request.
OUR ORGANIZATION
This notice describes the privacy practices of Community Provider of Enrichment
Services, Inc. (CPES). This notice also describes the privacy practices of individuals or
entities which have signed a contract with CPES, which are acting as business
associates and which have promised to follow the same rules of confidentiality. CPES
includes all services and supports provided by CPES, as well as CPES employees and
volunteers.
If you want to know more about the privacy practices of service providers who are not
employed CPES, and who are not business associates, you should contact them
directly.
Revised 07/16/07
CONTACT US
If you would like further information about your privacy rights, are concerned that your
privacy rights have been violated, or disagree with a decision that we made about
access to your personal information, you may contact:
CPES Privacy Officer
4825 N. Sabino Canyon Rd.
Tucson, AZ 85750
(520) 884-7954
We will investigate all complaints and will not retaliate against you for filing a complaint.
You may also file a written complaint with either:
The Secretary of the US Department of Health and Human Services
200 Independence SW
Washington, DC 20201
Phone: (877) 696-6775
The Office for Civil Rights, US Department of Health and Human Services
200 Independence Avenue SW, Room 509F, HHH Building
Washington, DC 20201
Phone: (800) 368-1019
E-mail: [email protected]
Revised 07/16/07
Notificación de Practicas Privadas
Esta notificación describe como la información medica de usted puede ser usada, revelada
y como puede tener acceso a esta información. Favor de examinar cautelosamente.
Privacidad Prometida
Community Provider of Enrichment Services, Inc. (CPES) sabe que tan importante es
mantener su información personal confidencial y promete seguir las leyes estatal y federal que
requiere estrictamente tener su información personal privada.
Como usaremos su información personal
Si usted es sostenido por CPES es probable que usemos se información personal en
servicios para usted. Servicios como facturaciones y cuando se lleve acabo nuestro negocio de
operaciones de su seguro medico.
Si usted eligió un representante personal y le accedió obtener información a su
representante personal. Si usted tiene un tutor nosotros le proveeremos la información a su tutor.
Unos ejemplos de cómo podemos usar su información incluyen lo siguiente:

Tratamiento-Nosotros obtenemos archivos de cuidados y servicios proveídos por CPES.
Por ejemplo, su coordinador de servicios, su supervisor de apoyo, consocio de Director,
cualquier personal importante obtiene notas en todos los contactos hechos en cordinacion
y puestos en servicio. Si usted ve a una enfermera o terapista que trabaja con CPES, ellos
le mantendran un archivo de cualquier cuidado que usted reciva. El personal de CPES
puede compartir su informacion personal por mientras ayudan a desarroyar un plan de
servicio para usted.
Si el personal de CPES quiere compartir su informacion personal con personas que no
nos empleados por CPES, usted primero debe de darles un permiso escrito.
Algunos archivos personales, incluyendo conversaciones confidenciales con un
profesional mental de salud e historial de abuso de substancias pueden tener restricciones
adicionales de uso.

Pago- Nosotros mantenemos un historial que incluye informacion de pagos y
documentacion del servicio que fue proveeido a usted. Su informacion puede ser usada
para obtener el pago de los servicios de AHCCCS, seguros u otras
fuentes. Por
ejemplo, nosotros podemos revelar informacion personal sobre los
servicios dados
a usted para confirmar su elegibilidad para AHCCCS y para
obtener pagos de
AHCCCS. CPES puede usar su informacion personal para
determinar la cantidad y
el tipo de servicio de AHCCCS que usted necesita y
esa informacion sera mandada
al departamento de estado apropiado.

Operacion de Cuidado Medico- Nosotros usamos informacion personal para mejorar la
calidad de cuidado, entrenamiento del personal, manejos de costo, asuntos que requieren
conducta para hacer mejoras en un plan de mejor servirle a usted y a otros individuos
apoyados por CPES. Por ejemplo, nosotros podriamos usas su informacion personal
para evaluar la calidad del tratamiento y proveerle servicios de nuestro personal.
Revised 09/09/08
OTROS SERVICIOS QUE LE PODEMOS PROVEER
Tambien podemos usar su informacion persoal para:









Determinar si usted es elegible para los servicios de CPES
Recomendarle sobre otras alternativas de servicios y otros posibles beneficios
Hacerle saber sobre otros servicios que podrian ayudarle a usted
Recordarle sobre su cita, al menos que usted le deje saber a nuestro personal de
CPES que no desea que le recuerde
Permitir que CPES le revise contratos de servicio directo
Permitir que agencial locales, estatales y federales monitoren sus servicios
Investigar cual quier incidente que afecte su salud y su seguridad, para asi reportar
este tipo de incidentes y tomar pasos para protejer su salud y seguridad
Permitir que CPES prepare reportes requeridos por la Division de Descapacidades
de Desarrollo
Contactarlo para asistencia en transcursos de salida, al menos que usted notifique
al personal de CPES que no desea ser notificado
COMPARTIR SU INFORMACION PERSONAL
En algunas situaciones limitadas cuando somos permitidos o que se requiere revelar informacion
personal sin tener su firma de autorizacion. Estas situacion son:













Para proteger a victimas de abuso, negligencia o violencia domestica
Para reducir o evitar una seria amenaza a la salud publica y seguridad
Para su vigilancia de salud en actividades como investigaciones, tribunal e
inspecciones
Para demandas y procedimientos similares
Para propositos de salud publica, asi como repotes de enfermedades contagiosas,
accidentes causados en el trabajo u otras enfermedades y lesiones, como
permitidas por ley; reportando nacimientos y fallecimientos y reportando reacciones
a drogas y problemas con equipo medico
Cuando es requerido por ley
Cuando es solicitado por agentes de ley, como requerido por ley o por una orden
de la corte
Cuando el agente de ley esta respondiendo a una emergencia a una facilidad de
CPES
Para coroner, examinador medico y directores de funeraria
Para donante de organo y tejido
Para Compensacion de Trabajadores o cual quier programa similar, si usted a sido
lesionado en su trabajo y la Compesacion de Trabajadores lo cubre u otro
programa similar
Para funciones de govierno especializadas, como inteligencia y seguridad nacional
Para ayuda catastrofe
Todos los otros usos de revelacion no describidos en esta nota requieren su firma de autorizacion.
Usted puede derogar su autorizacion en cual quier momento en una declaracion por escrito.
Revised 09/09/08
RESPONSABILIDADES DE PRIVACIDAD DE CPES'
CPES es requerido por ley que:



Su informacion personal se mantenga privada
Proveer esta informacion que describe las formas en las cuales nosotros podemos
compartir su informacion personal
Seguir los terminos que estan en efecto en la nota actulisada
Nosotros reservamos el derecho de hacer cambios en esta nota a cual quier
tiempo y hacer los nuevos cambios de practica de privacidad para toda la
informacion que nosotors mantenemos. Avisos actuales seran puestos en todas las
facilidades de CPES y en la pagina de internet de CPES. Usted tambien puede
solicitar una copia de cual quier aviso de la Oficina de Privacidad CPES
SUS DERECHOS INDIVIDUALES
Usted tiene el derecho de:






Pedir restricciones en el uso y como compartimos su informacion personal. CPES
considerara todo tipo de peticion para restricciones cuidadosas, pero no es
requerido que acepte ninguna restriccion.*
Pedir que nosotros usemos numeros de telefono especificados o direcciones para
comunicarnos con usted
Inspeccionar y copiar su informacion personal, incluyendo servicio, archivo medico
y facturas. Puede aplicar cuota.*
Pedir correcciones o informacion personal adicional. Ustede debe de darnos una
rason por la cual quiere hacer el cambio. *
Pedir una contabilidad en ciertas revelaciones de su informacion personal echa por
nosotros. Su pedido tendra que declara el periodo de tiempo deseado por la
contabilidad, que deve de ser en un periodo de 6 anos a su peticion. La primera
contabilidad es gratis, pero una cuota puede aplicar si mas de una peticion es echa
en un periodo de 12 meses.*
Pedir la copia de este aviso en papel aunque usted ayga acordado en recivir este
aviso electronicamente.
*Pedidos senalados con una estrella (*) deven de ser echos por escrito. Pongase en contacto con
la Oficina de Privacida de CPES para un pedido apropiado en una forma.
NUESTRA ORGANIZACION
Este aviso describe las practicas de privacidad de la Comunidad Proveedora de Servicios de
Enriquecimiento, Inc. (CPES). Este aviso tambien describe la privacidad de practicas individuales
o titula el cual a sido un contrato firmado con CPES, el cual actua como asociados de empresa y
que le prometen el seguir las mismas reglas confidencialmente. CPES incluye todo los servicios y
provee apoyo de CPES, al igual que empleados de CPES y voluntarios.
Si usted desea saber mas sobre las practicas de privacidad de servicios que provee quien es o no
es empleados de CPES, y quienes no son asociados de la empresa, usted deve contactarlos
directamente.
Revised 09/09/08
PRN Consent Form
Name
Date
ALLERGIES:
WEIGHT
DOB:
PRINTED NAME OF PHYSICIAN
Medications
Dose
Tylenol
2 tablets (250mg)
Ibuprophen
1-2 tablets (200 mg)
Instructions
by mouth every 4-6 hours as needed for pain or
temperature over 101
by mouth every 4-6 hours as needed for pain or
temperature over 101
Milk of Magnesia
2-4 Tablespoons
daily as needed for constipation.
Robitussin
Dimetapp
tablets/capsules
Debrox/generic ear
drops
2-4 Teaspoons
1 tablet (120 mg)
every 4 hours as needed for cough
every 12 hours as needed for nasal congestion *consult
physician for interaction with MAOI's
5-10 drops
per ear for wax accumulation
Benadryl
1-2 tablets (25-50 mg) every 4-6 hours for allergies
Kaopectate/ generic
2 Tablespoons
as needed for 3 watery stools within a 24 hour period
Maalox
Tinactin
cream/ointment
2-4 Teaspoons
as needed for upset stomach
2 x daily
Caladryl Lotion
Bowel Program
Recommendation
Neosporin/Triple
Antibiotic Ointment
3-4 x daily
apply to athletes foot as needed
apply to insect bite as needed for itching *apply to
affected area no more than 3-4 x daily
note plan or recommendations as applicable
1-3 x daily
apply to clean/dry affected area
Hydrocortizone Cream 0.50%
apply to affected area no more than 3-4 x daily
Bactine
wash affected area with small amount 1-3 x daily
Blistex Medicated
Artificial Tears eye
drops
apply liberally to affected area for chapped lips
2 drops
per eye for minor irritation
Physician: please indicate any corrections with a single line and initials.
May generic products be substituted?
Physician's Signature
Yes
No
Date
rev 03/11/09
Informed Consent to Participate in Telemedicine Services
I, _______________________________, have been asked to receive behavioral health services via
telemedicine. I have been informed of my diagnosis and proposed telemedicine treatment plan. I
understand that I will be receiving health care services through interactive videoconferencing equipment.
I understand that, at this time, there are no known risks involved with receiving my care in this way.
I understand that the equipment will be shown to me and I will see how it works before I receive any
services. I understand that my participation in telemedicine is voluntary and I may refuse to participate
or decide to stop participation at any time. I understand that my refusal to participate or decision to stop
participation will be documented in my medical record. I have been informed of the potential
consequences of my revocation of informed consent to treatment.
I understand that my privacy and confidentiality will be protected. I also understand that the likelihood
of a videoconference being intercepted by an outsider is similar to the potential interception of a phone
call. When I am receiving services via telemedicine, I will be notified as to who is in the room at the
remote site.
I understand that the health care providers at both my location and the remote video site will have access
to any relevant medical information about me including any psychiatric and/or psychological
information, alcohol and/or drug abuse, and mental health records.
I have read this document and I hereby consent to participate in receiving behavioral health services via
telemedicine under the terms described above. I understand this document will become a part of my
medical record.
Please check the appropriate box below.
□ I agree to participate in and receive behavioral health services via telemedicine.
□ I have chosen not to participate in telemedicine sessions.
____________________________ _______________
Member Signature
Date
____________________________
Witness Signature
_____________
Date
The above release is given on behalf of ______________________ because the member is a minor or
has been determined to be incompetent to give medical consent.
____________________________
______________
Parent, Legal Guardian, or Government Agency Date
Authorized by the Court (Copy of Court Order Attached)
____________________________
Relationship to Client
____________________________
Date
____________________________
Witness Signature
HOMESTEAD
HOMESTEAD NORTH
Informed Consent for Psychotropic Medication Treatment of Minor
Patient Name: _________________________
Date of Birth:
Medical Record #:________________
___________________
Name of Parent/Legal Guardian: ____________________
I, ______________________________, have discussed the following information with the
minor’s health care provider for each medication listed below:










The diagnosis and target symptoms for the medication recommended;
The possible benefits/intended outcome of treatment, and as applicable, all
available procedures involved in the proposed treatment;
The possible risks and side effects;
The possible alternatives;
The possible results of not taking the recommended medication;
The possibility that the medication dose may need to be adjusted over time, in
consultation with the minor’s health care provider;
In the event that the minor becomes pregnant, plans pregnancy, or plans to
breast feed, I will notify the minor’s health care provider. I understand that some
medications may not be safe under these circumstances;
In the event that I have any concerns about the minor’s symptoms after a
medication has been prescribed or changed, I will immediately notify the health
care provider;
My right to actively participate in the minor’s treatment by discussing medication
concerns or questions with my health care provider; and
My right to withdraw voluntary consent for medication at any time (unless the use
of medications in the treatment is required in a Court Order or in a Special
Treatment Plan).
I understand the medication information that has been provided to me. By signing below I agree
to the use of each medication for the minor.
I recognize and understand that the prescription may represent an “off-label” use of the
medication, and that the physician has discussed with me the specific purpose of each
medication for the minor.
Medication
How Discussed
___In person
___Telephone
___Telemedicine
___Previously
Parent/Legal
Guardian/Authorized
Custodial Agency
Initials & Date
Health Care
Provider
Initials & Date
___In person
___Telephone
___Telemedicine
___Previously
___In person
___Telephone
___Telemedicine
___Previously
___In person
___Telephone
___Telemedicine
___Previously
___In person
___Telephone
___Telemedicine
___Previously
___In person
___Telephone
___Telemedicine
___Previously
___In person
___Telephone
___Telemedicine
___Previously
_______________________________
Parent/Legal Guardian
_____________________________
Date
_________
Initials
_________________________
Health Care Provider Signature
_____________________________
Health Care Provider Name Printed
_________
Initials
_____________________________
Date
“Previously” discussed indicates that the medication had been discussed in a previous setting or by
another prescriber (hospital, another clinic, etc.) and the health care provider is verifying that the patient
continues to consent to treatment with this medication.
Ensure informed consent form with original patient signature is located in patient’s file. If consent is
obtained by telephone or through telemedicine, the patient may initial and date at next face-to-face visit.
House Rules
Homestead
Homestead North
CPES Main Office
4825 N Sabino Canyon Rd
Tucson, AZ 85750
Phone (520) 884-7954
HOURS
For emergencies before 8:00 a.m. and after 5:00 p.m. contact Kurt Forrest at (520) 349-1490, if there is no answer within fifteen minutes, then
contact Brad Waters at 602-370-7278.
Homestead is a child based assessment and intervention setting.
Homestead Staff Office will generally be open Monday—Friday 8:00 a.m.
—5:00p.m.
VISITORS
All visitors must have prior approval when visiting the Homestead program. Visiting hours are Saturday from 2:00 p.m.—4:00 p.m. Visitors
must adhere to Homestead house rules. Visitors are only allowed with
proper identification and must be on an approved contact list per the
Program Manager.
House Rules
Setting Rules
House Rules:










Respect others
No contraband
No drugs or alcohol
No gang activity
Appropriate boundaries i.e. personal contact with peers or staff
Attend groups/activities
Respect property
Follow treatment goals
No stealing, swearing or lying
No smoking in house or on the grounds
Personal Room Expectations:






No food or beverages, except water
To promote safety for peers and staff: When necessary room searches will be completed for any unsafe objects
Clients are not allowed to move furniture
Clients are not allowed to be in each others room and roommates, if applicable, are not allowed to
be on each other’s bed.
Bedroom doors are to remain open at all times
Bedrooms are to remain clean and presentable, i.e. making beds, folding clothes before morning
group, etc.
Chores


Clients are responsible for keeping their room and bathroom cleaned
Clients must clean up after themselves
Hygiene




All consumers must shower daily and wear clean clothes
Facility possession may be required at times of consumer hygiene products. If this occurs a check
out system will be implemented.
Clients shall bring their personal hygiene products upon admission. If not available some may be
provided until purchased or drop off.
All razors will have to be checked out on a daily basis before goals group.
House Rules
Dress Code








Clothes endorsing paraphernalia, alcohol, sex, drugs or violence are not permitted.
No mid drifts, skull caps or undergarments shall be visible.
Management may request a turn in of an item if deemed inappropriate
All jewelry must be turned in or not brought in while being admitted. If jewelry is present it shall
be locked in secure manner and returned upon discharge.
Shoes must be worn at all times
Proper sleep attire including t-shirts must be worn by male consumer
No gang or gang affiliated colors including bandanas shall be worn
No giving or borrowing of any clothing or personal hygiene item is allowed
Laundry


Laundry will be completed by the clients on designated laundry days
Clients are expected to wash, dry, fold and place their clothes in their designated areas
Visitation

Visitation shall occur as deemed appropriate by the CFT and interdisciplinary team.
Telephone Use






Upon admission intake coordinator shall determine an appropriate phone call/Contact list placed in
client’s file
Staff will place phone calls for the client’s.
Calls may be terminated upon verbal/physical aggression as deemed by staff
English must be the primary medium for communication unless prior approval is made
All incoming phone calls must be screened and handled accordingly with relation to current HIPPA laws
Phone calls shall not exceed fifteen minutes, unless prior approval is noted.
Cell Phones


If a client is admitted with a cell phone it will be held by the facility and documented in personal
property inventory. When the client is discharged the cell phone will be returned to the client
along with all other personal property.
Cell phones are not allowed for client use during their stay.
House Rules
Meal Etiquette





Clients must be dismissed upon leaving the meal areas, i.e. bathroom, second helping, etc.
Clients are required to stay at the dinner table until all clients are finished consuming their meal.
Clients shall enter the dining room and remain seated until meals are served.
All clients shall receive three meals and three snacks a day.
Clients displaying inappropriate behavior shall be dismissed from the dinner table
Financial

Any money the client is admitted with will be held by the facility and documented in personal
property inventory. When the client is discharged the money will be returned to the client along
with all other personal property.
Mail


All clients mail shall be opened in front of staff to ensure the safety of the clients.
Mail will be distributed and mailed on a daily basis.
Family/CFT members
Shall:
 Be willing to listen
 Be respectful to consumers’ input and ideas
 Be wiling to make concessions
 Assist in developing an aftercare plan for ongoing treatment
Staff
Shall:
 Be willing to learn from a child as they learn from you
 Continue with ongoing clinical supervision to increase knowledge and use that knowledge to be
more effective.
House Rules
Counseling and groups

Shall be youth focused and relate to current behavior modification
There shall be at least three groups a day using ice breakers, de-inhibitizers, and energizers. The groups
consist of a morning group (goals group) afternoon and evening group (wrap up)
Groups shall be run in a combination of BHT and Client and last from thirty minutes to an hour depending upon participation and topic. Accomplished through trust and team building activities we can
increase communication and teamwork.
Group Topics











Taking responsibility for your actions
Alcoholics’ anonymous, Narcotics anonymous
Peer pressure
Self awareness
Effective communication
Current events
Increasing self esteem
Family dynamics
Anger Management
Coping skills
Identifying and managing emotions











Community resources
Empathy
Friendship
Recognizing crisis and how to deal with it
Open discussion groups
Identifying thinking errors
Respect and Morals
Accountability and Consequences
Depression, Anxiety, and Hope
Boundaries
**additional groups will occur as needed
Client Signature
Date
Guardian Signature
Date
Staff Signature
Date
Client Admit Checklist
Intake Client Info Sheet Complete
Signed Agency Phone Numbers, Addresses, and Miscellaneous Information
Signed Informed Consent by Client/Guardian
Signed General Consent by Client/Guardian
Signed Client Rights
Signed HIPPA Acknowledgement by Guardian
Signed Grievance Policy and Procedure by Client/Guardian
Signed Authorization to Release/Receive/Exchange
Signed House Rules by Client/Guardian
Signed Consent for Psychotropic Medication Treatment by Client/Guardian
Signed Minor’s Consent to Participate in Telemedicine by Client/Guardian
Signed PRN Consent form by Prescriber
Signed Intake Self Medication Form by Prescriber, Case Manager, Client, Guardian
Core Assessment (Signature Page, Part A, B, C, D and Demographics)
Part E of the Core Assessment if the Client has been in the system for more than a year.
Current Crisis/WRAP Plan
ITP Letter for NARBHA Clients
Behavioral Health Service Plan with Homestead Program and CCS listed as providing services.
Strengths, Needs, and Cultural Discovery Assessment
All past psychological and/or psychiatric evaluations
Current TB – PLEASE WAIT UNTIL ADMISSION IS SCHEDULED!
Current Physical - PLEASE WAIT UNTIL ADMISSION IS SCHEDULED!
Copy of the insurance Card—Necessary to ensure which ACCCHS plan Client is under.

Homestead Program 14921 W Camdon Drive Casa Grande, AZ

Transcription

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