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Consent for Admission and Client Orientation (Web)

Community & Family Resources
211 Ave M West
Phone 515-576-7261
Fax 515-955-7628
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Date
Medicaid #
Medicare #
I consent to admission for specific behavioral health treatment services, understand the treatment recommendations made, and consent to participate in those services at Community and Family Resources.  I understand that while counseling, therapy and/or medication, may provide significant benefits, it may also pose risks.  Counseling and therapy may elicit uncomfortable thoughts and feelings, or may lead to recall of troubling memories.  Medications may have unwanted side effects.  Please note: Some services may be performed by “The Richmond Center”.
Additionally:
I have received a copy of my group and/or treatment schedule and the CFR Client Handbook, if desired and that I have read, and/or have had explained to me and understand the following information from the handbook:

--The general nature and goals of the program, rules governing client conduct (including infractions of the rules that can lead to disciplinary action or discharge from the program).
--Hours during which services are available.
--The disaster/safety plan for the facility I am to receive treatment.
--My treatment fees and that payment is due at the time of service.
--Program expectations and facility safety.
--CFR is a tobacco, drug, alcohol, gambling, and weapon free zone and I am subject to random searches.
--Client rights and responsibilities, confidentiality regulations, and religion/spirituality services.
--CFR’s Grievance Procedure.

As a courtesy to other potential consumers, CFR has opted to implement a policy in regards to appointments that are not attended successfully.  Consistent attendance at all scheduled activities contained in each person’s treatment plan will be of the most benefit in reaching agreed-upon recovery goals.  When an individual has a no-show or late cancellation (less than 24 hour advance notice) the individual will be contacted by an Engagement Specialist to ascertain if an alternative scheduling plan or other remedies are appropriate.  When the individual reaches three (3) no-show/late cancellations over a 90 day period, the individual must talk with the Engagement Specialist to determine the requirement for the scheduling of any future services, which may include attending Motivational/Engagement Group sessions.  If the individual reaches four (4) no-show/late cancellations over a 90 day period or declines to attend Motivational/Engagement Group, CFR will assume they are no longer interested in further services and they will be discharged and in-eligible for services for 90 days.  Please see the Client Engagement Policy for full details.

I understand and agree that in order to successfully complete treatment, I must adhere to and comply with all program requirements and treatment issues set forth in my treatment plan.  Treatment requirements include, but are not necessarily limited to the following:

--Total participation in all scheduled appointments and activities unless prohibited by a documented medical emergency or cancellation of activities by the service provider.
--Complete payment for all cost(s) incurred during my involvement with Community and Family Resources.  Failure to pay on my bill may result in my discharge letter not being sent to the referral source.  After 90 days of non-payment, CFR reserves the right to pursue other collection arrangements.
--Adequate progress in the program as judged by the clinical staff.

I understand that I will receive the opportunity to provide feedback by filling out surveys throughout my treatment.  I have indicated how I would like to receive those surveys.

I understand that for research, Community and Family Resources may release my name and other contact information to the Iowa Consortium for a follow up interview regarding my treatment experience.  I may be randomly selected from the data that is reported to the State of Iowa.  The follow-up interview may occur up to one year after my treatment ends.  My records are protected by Federal Confidentiality Regulations and cannot be disclosed to any other source without my specific written consent.  Additionally, I understand that I may receive a follow up call or email to conduct a treatment satisfaction survey during treatment and post discharge.

I understand that as part of my treatment, general duty medical and nursing care may be necessary.  I hereby authorize the medical director/staff physician to provide medical and/or surgical treatment as he/she considers necessary and proper in my treatment for the purpose of correcting my condition.  I understand that if I am participating in adult residential treatment, CFR provides 24-hour general duty nursing care as part of my treatment.  I understand that any nursing services above and beyond general duty nursing care as determined appropriate for my care by the medical/nursing staff will result in me and/or my guardian being billed for additional services and that my insurance company/third-party payor may not cover these additional services and that I and/or my guardian will be responsible for payment of these additional services.

I understand that this consent for services is effective for the duration of my treatment at Community and Family Resources unless expressly revoked.

ADOLESCENTS ONLY: I understand and give consent to be screened for gambling treatment services by a qualified gambling treatment professional.

My signature or the signature of a guardian in my place indicates that this consent form has been explained to me in a language that I can understand, and that I or my guardian agree with the above.
* Is the client willing and able to sign in agreement?
Yes  
No  
If not, explain:
* Signature of Client:
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
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Signature of Legally Authorized Representative:
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
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