Please fill out this form completely. The following information will help us in providing you the best care and treatment possible. If you have any questions, please contact the office. Thank you and we look forward to seeing you!
Patient/Client Information
Name of person to receive services whether yourself, your child, or someone you are enrolling in the program
Race
Ethnicity
name of clinic or doctor you visit for checkups and will use for medical treatment
Insurance Information
Name of insurance, ex. United Healthcare, Texas Childrens, Superior, Amerigroup, Community Health Choice, Molina
Medical History
if none write None
Legal Authorized Representative (LAR) for Minor Child
Relationship to Client
I Certify that I have the right to make treatment decisions for the client (myself or minor in my custody) *
If evidence of Custody is required/requested, I am aware I will need to share it with Alpha Recovery before services begin.
Patient's Bill of Rights
When you apply for or receive mental health services in the State of Texas, you have many rights. Your most important rights are listed on the following pages. These rights apply to all persons unless otherwise restricted by law or court order. A judge or lawyer will refer to the actual laws. If you want a copy of the laws these rights come from, you can call the Health Facility Licensure and Certification Division of the Texas Department of State Health Services at 1-888-973-0022. It is the responsibility of this entity under law to make sure you have been informed of your rights. But just giving you this information does not mean your rights have been protected. This entity is required to respect and provide for your rights in order to maintain licensure and do business in this state. Your Right to Know Your Rights You have the right, under the rules by which this entity is licensed, to be given a copy of these rights before you receive services. If you so desire, a copy should also be given to the person of your choice. If a guardian has been appointed for you or you are un- der 18 years of age, a copy will also be given to your guardian, parent, or conservator. You also have the right to have these rights explained to you aloud in simple terms in a way you can under- stand within 24 hours of receiving services (e.g., in your language if you are not English-speaking, in sign language if you are hearing impaired, in Braille if you are visually impaired, or other appropriate methods). Your Right to Make a Complaint You have the right to make a complaint and to be told how to contact people who can help you. These people and their addresses and phone numbers are listed below. If you believe any of your rights have been violated or you have other concerns about your care, you may contact one or more of the following: If you are receiving services from a private facility, you can call: Health Facility Licensing and Compliance Division Texas Department of Health 1100 W. 49th Street Austin, TX 78756 1-888-973-0022 If you are receiving services from a DSHS State Hospital or facility, you can call: Consumer Services and Rights Protection Texas Department of State Health Services, MHSA P.O. Box 149347, MC: 2019 Austin, TX 78714-9347 1-800-252-8154 Whether you are receiving services from a private facility or a DSHS State Hospital or facility, you can call: Disability Rights Texas 7800 Shoal Creek Blvd., Suite 171-E Austin, TX 78757 1-800-315-387
Basic Rights for All Persons Receiving Mental Health Services
1. You have all of the rights of a citizen of the State of Texas and the United States of America, including the right of habeas corpus (to ask a judge if it is legal for you to be kept in the hospital), property rights, guardianship rights, family rights, religious freedom, the right to register to vote, the right to sue and be sued, the right to sign contracts, and all the rights relating to licenses, permits, privileges, and benefits under the law. 2. You have the right to be presumed mentally competent unless a court has ruled otherwise. 3. You have the right to be treated without dis- crimination due to your race, religion, sex, ethnicity, nationality, age, sexual orientation, or disability. If you believe you have been discriminated against for any of the reasons listed above, you may contact the HHSC Civil Rights Office at 1-888-388-6332. 4. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity. 5. You have the right to appropriate treatment in the least restrictive appropriate setting available that provides protection for you and for the community. 6. You have the right to be free from mistreatment, abuse, neglect, and exploitation. If you believe you have been abused, neglected, or exploited, you should contact DFPS at 1-800- 647-7418. 7. You have the right to protection of your personal property from theft or loss. 8. You have the right to be told in advance of all estimated charges being made, the cost of services provided, sources of the program’s re- imbursement, and any limitations on length of services. As part of this right, you should have access to a detailed bill of services, the name of an individual at the facility to contact for any billing questions, and information about billing arrangements and available options if insurance benefits are exhausted or denied. 9. You have the right to fair compensation for labor performed for the hospital in accordance with the Fair Labor Standards Act. 10. You have the right to be informed of those pro- gram rules and regulations concerning your con- duct and course of treatment. 11. You have the right not to be unnecessarily searched unless your physician believes there is a potential danger and orders a search. If you are required to remove any item of clothing, a staff member of the same sex must be present, and the search must take place in a private place. Confidentiality 12. You have a right under HIPAA (Health Insurance Portability and Accountability Act) to have your confidentiality rights explained to you at admission. You will be provided a written copy of your confidentiality rights, including how to make a com- plaint. 13. You have the right to review the information contained in your medical record. If your doctor says you shouldn’t see a part of your record, you have the right to file a complaint with the entity’s HIPAA privacy officer. You may also, at your expense, have another doctor of your choice review that decision. The doctor must also reconsider the decision to restrict your right on a regular basis. The right extends to your parent or conservator if you are a minor (unless you have admitted yourself to services) and to your legal guardian if you have been declared by a court to be legally incompetent. 14. You have the right to have your records kept private and to be told about the conditions under which information about you can be disclosed without your permission, as well as how you can prevent any such disclosures. 15. You have the right to be informed of the cur- rent and future use of products of special observation and audiovisual techniques, such as one-way vision mirrors, tape recorders, television, movies, or photographs. Consent 16. You have the right to refuse to take part in research without affecting your regular care. 17. You have the right to refuse any of the following: Medications; Behavior therapy; Audiovisual equipment; and, Other procedures for which your permission is required by law. This right extends to your parent or conservator if you are a minor, or your legal guardian when applicable. 18. You have the right to withdraw your permission at any time in matters to which you have previously consented. Care and Treatment 19. You have the right to be transported to, from, and between facilities in a way that protects your dignity and safety. You have the right not to be transported in a marked police or sheriff’s car or accompanied by a uniformed officer unless other means are not available. You have the right to a treatment plan that is just for you. You have the right to take part in developing that plan, as well as the treatment plan for your care after you leave the program. This right extends to your parent or conservator if you are a minor, or your legal guardian when applicable. You have the right to request that your parent/conservator or legal guardian take part in the development of the treatment plan. You have the right to request that any other person of your choosing, e.g., spouse, friend, relative, etc., take part in the development of the treatment plan. You have a right to expect that your request be reasonably considered and that. you will be informed of the reasons for any denial of such a request. Staff must document in your medical record that the parent/guardian, conservator, or other person of your choice was contacted to participate. 20. You have the right to be told about the care, procedures, and treatment you will be given; the risks, side effects, and benefits of all medications and treatment you will receive, including those that are unusual or experimental, the other treatments that re available, and what may happen if you refuse the treatment. 21. You have the right to receive information about the major types of prescription medications which your doctor orders for you. 22. You have the right not to be given medication you don’t need or too much medication, including the right to refuse medication (this right extends to your parent or conservator if you are a minor, or your legal guardian when applicable). However, you may be given appropriate medication without your consent if: Your condition or behavior places your or others in immediate danger; or you have been admitted by the court and your doctor determines that medication is required for your treatment and a judicial order authorizing administration of the medication has been obtained. 23. You have the right to request the opinion of another doctor at your own expense. You have the right to be granted a review of the treatment plan or specific procedure by program staff. This right extends to your parent or conservator if you are a minor, or your legal guardian, if applicable. 24. You have the right to be told why are being transferred to any program within or outside the agency. 25. You have the right to a periodic review to determine the need for continued treatment.
I have received and reviewed this document and understand my rights prior to receiving services. *
Consent for Assessment and Treatment (Services)
I voluntarily authorize Alpha Recovery, LLC and such health care providers as it may deem necessary to provide mental health treatment, including but not limited to crisis intervention services, medication training and support services, skills training and development services, psychotherapy, and medication management, to my child. I understand that no warranty or guarantee has been made to me as to result or cure. I affirm that I have the authority to make mental health care decisions for myself or my child, including but not limited to decisions regarding psychiatric and psychological treatment, and I am aware that all custodial parents (managing conservators) or guardians must give consent before mental health treatment is provided. I have been given an opportunity to ask any questions I may have regarding the mental health treatment to be provided to myself or my child, and I believe that I have sufficient information to give this informed consent. I understand that I can revoke my consent at any time. I understand that the information listed below will be explained to me by trained staff at my orientation and will become part of my records: a) the program’s services and treatment b) the expected charges for services c) the client’s Rights and Responsibilities c) the procedures for complaint and question resolution. I understand that while psychotherapy and/or medication treatments may provide significant benefits, it may also pose risks including unwanted side effects. I have read and understand the above statements.
Signature of Client (adult) or LAR (child/minor)
Consent for Telehealth Services
I voluntarily authorize Alpha Recovery LLC and such health care providers as it may deem necessary to provide mental health treatment to my child through telehealth services, including but not limited to crisis intervention services, medication training and support services, skills training and development services, psychotherapy, and medication management, using advanced telecommunications technology. I understand that telehealth services include interactive audio, video, or other electronic media and that there are both risks and benefits to being treated via telehealth. I understand that the telehealth providers (i) may be in a location other than where my child is located, (ii) will examine or evaluate my child face-to-face via a remote presence but will not perform a physical examination while using the telehealth services, and (iii) must rely on information provided by my child and / or my child’s parent, managing conservator, or guardian. I further understand that telehealth services may be limited or unavailable as a result of technological or equipment failures, incomplete or inaccurate data to perform the telemedicine services, or distortions of images or other information from electronic transmissions. I acknowledge that the telehealth providers cannot be held liable for advice, recommendations and / or decisions based on factors not within their control, such as incomplete or inaccurate data provided by my child / others or distortions of diagnostic images or specimens that may result from electronic transmission. I understand that the telehealth providers, myself, my child or child’s parent/ guardian can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation. If the telehealth session is interrupted, alternative treatment may be needed, and I will obtain follow up care and treatment for my child as needed. I understand that precautions are taken to protect the confidentiality of my child’s mental health information by preventing unauthorized disclosure; however, I understand and acknowledge that the security of electronic transmission of data, video images, and audio information cannot be guaranteed and confidentiality may be compromised by illegal or improper tampering. I understand that no warranty or guarantee has been made to me as to result or cure. I affirm that I have the authority to make mental health care decisions for myself/my child, including but not limited to decisions regarding psychiatric and psychological treatment, and I am aware that all custodial parents (managing conservators) or guardians must give consent before mental health treatment is provided. I have been given an opportunity to ask any questions I may have regarding the mental health treatment to be provided to my child through telehealth services, and I believe that I have sufficient information to give this informed consent. I understand that I can revoke my consent at any time.
Signature of Client (Adult) or LAR (child/minor) *
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. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record: •You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. •We will provide a copy or a summary of your health information, usually within 15 days of your re- quest. We may charge a reasonable, cost-based fee. Ask us to correct your medical record: •You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. •We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications: •You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. Ask us to limit what we use or share: •You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. •If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information: •You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. •We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We may charge a reasonable, cost-based fee. Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. Choose someone to act for you: •If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. •We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated: •You can complain if you feel we have violated your rights by contacting us using the information on page 1. •You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1- 877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. •We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, we will follow your instructions. In these cases, you have both the right and choice to tell us to: •Share information with your family, close friends, or others involved in your care •Share information in a disaster relief situation. •Include your information in a hospital directory. If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: •Marketing purposes •Most sharing of: mental health records (excluding psychotherapy notes); psychotherapy notes; drug, alcohol, or substance abuse records; genetic information (including genetic test results); and HIV/AIDS test results and/or treatment records Our Uses and Disclosures We typically use or share your health information in the following ways. Treat you: We can use your health information and share it with other professionals who are treating you. Run our organization: We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. Bill for your services: We can use and share your health information to bill and get payment from health plans or other entities. We are allowed or required to share your information in other ways—usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: •Preventing disease •Helping with product recalls •Reporting adverse reactions to medications •Reporting suspected abuse, neglect, or domestic violence •Preventing or reducing a serious threat to anyone’s health or safety Do research: We can use or share your information for health research. Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director: We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: •For workers’ compensation claims •For law enforcement purposes or with a law enforcement official •With health oversight agencies for activities authorized by law •For special government functions such as military, national security, and presidential protective ser- vices Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities •We are required by law to maintain the privacy and security of your protected health information. •We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. •We must follow the duties and privacy practices described in this notice and give you a copy of it. •We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice: We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
I understand my right to the privacy of my Healthcare Records
Consent to Electronic Communication Methods
I understand Alpha Recovery LLC uses a variety of communication methods including phone, text messages, email to communicate with me for the limited purposes of appointments, available services, and other healthcare related communications. I authorize Alpha Recovery LLC to disclose limited protected health information to other persons who may answer my electronic communications such as phone, text messages, or email. These may include information about appointments, available services or healthcare related communications. I have the right to revoke this consent, in writing, at any time except to the extent that Alpha Recovery LLC has taken action in reliance of this consent.
Signature of Client (adult) or LAR (child/minor)
Consumer Grievance Instructions
1. If you have a concern or grievance, we encourage you to bring your concern or grievance to the attention of the staff person involved. The staff person will address your concerns and attempt to resolve the grievance. 2. If you are unable to complete the first step or if your concern or grievance has not ben resolved by meeting with the staff person concerned, you may request an interview with that staff person’s immediate supervisor. This request may be made in writing, by telephone, or in person. Upon request receipt, the supervisor will contact you within 48 working hours. 3. If your concern or grievance is still not resolved to your satisfaction, you may request a mediation session with the assistance of a trained mediator, both parties can try to reach a mutually satisfactory resolution. 4. If you choose not to have a mediation session, or it does not resolve the grievance, you may have a Review Hearing. The Review Hearing will be scheduled within 15 working days of your request. You may have an advocate or supportive person with you. We will keep minutes to provide you with a written response within 7 working days of the meeting. 5. If your concern or grievance is still not resolved to your satisfaction, please contact the Texas Health and Human Services office.
Signature of Client (adult) or LAR (child/minor)
Client Disclaimer, Release of Liability Notice Agreement
Alpha Recovery LLC shall employ reasonable measures to ensure the safety and welfare of their Clients. These reasonable precautions shall be determined to be those acts and/or measures that any reasonable person would employ or demonstrate under the same or similar circumstances. Alpha Recovery LLC shall not be held responsible or liable in any manner and is hereby released from any and all liability or acts that may be committed by any “Client” or “Client’s representative” against another “Client” or “Client’s representative” or any other persons during any meeting, function, activity and/or event Alpha Recovery LLC may host or sponsor on or off their premises. Pursuant here to “on premises” shall be defined as being conducted, sponsored and/or held in or on any property, grounds, and/or buildings owned or perpetually leased by Alpha Recovery LLC. “Off premises” shall be defined as any location, building, park, mall, theatre, restaurant, arcade, theme park, owned, leased, and/or operated by any other organization, corporation, or individual other than Alpha Recovery LLC. “Perpetual Leases” for the purpose of this Disclaimer Release of Liability Notice/Agreement shall be defined as “property leases” and shall not be determined to include any type of interim lease designed for a specific event or purpose. Specifically, whenever Alpha Recovery LLC hosts and/or sponsors any meetings, function, activity, or event, whether held on or off any premises or property leased or owned by Alpha Recovery LLC, they shall not be assumed or determined to have assumed any liability and is hereby released from any and all liability for “clients” or “client’s representative” acts or actions that may be interpreted to cause or have caused harm to any other “client” or “client’s representative” or person during that person’s presence at the meeting, function, activity, and/or event hosted and/or conducted by Alpha Recovery LLC on or off their premises. Any person and/or entity acting on behalf of Alpha Recovery LLC must possess express written consent/permission to act on their behalf in any capacity. Such written consent or permission shall not be assumed to create liability for Alpha Recovery LLC for the acts or actions of such individuals or entities. Alpha Recovery LLC is also released from nay liability with regard to any acts of third parties, whether vendors, contractors, or invitees that may be interpreted as harmful to any “clients” or “client’s representative” either on or off premises. This Disclaimer Release of Liability Notice Agreement shall be deemed executed as of the date of signing, represented by the date signed below.
Signature of Client (adult) or LAR (child/minor)
Transportation Waiver Form
I hereby give permission that the client may participate in and travel to and from and/all destinations for the duration of services provided by Alpha Recovery LLC. I understand that the driver, vehicle owner, and Alpha Recovery, LLC are not responsible for any injury/damages which may be incurred on said trip, and in consideration for providing transportation, I agree to hold Alpha Recovery LLC as well as the drivers and owners of the vehicles transporting the consumer, harmless from claims for injury or damages occurring during the travel.
Signature of Client (adult) or LAR (child/minor)
please upload an image of client ID or parent/guardian ID for minors Image size must be less than 10MB.
please upload an image of the client's insurance card Image size must be less than 10MB.
A Copy of this Consent Form will be sent to your email at your intake appointment.
New Client and Yearly Consents for Services will be submitted to Alpha Recovery, LLC
