• NAME OF SERVICE PROVIDER: HEADS - HEALING EDUCATIONAL ALTERNATIVES FOR DESERVING STUDENTS

    I Hereby authorize any of the parties designated below to communicate with one another through disclosure, receipt and use of my confidential information for purposes of evaluating my needs, coordinating and/or providing services to me. Any disclosure, receipt or use of information by the parties will be limited to the minimum that is reasonably necessary to accomplish the intended purpose.

    CHECK YES OR NO FOR ALL AREAS. THIS DOCUMENT IS NOT VALID UNLESS EVERY ITEM IS CHECKED YES OR NO.

  • Handbook & Policy Acknowledgement

    Welcome to HEADS
    We’re pleased that you have chosen our agency.
    This handbook was created with the participation of consumers, family and support network members, advocates, and agency staff. It is provided as a guide to acquaint you with our mission and values, services and policies as well as your rights and responsibilities as our client.


    HEADS’s Mission
    To provide clinical services unique to each individual in any environment they find most challenging, and focus on individual strengths so each client has the chance to achieve their highest potential.

    Philosophy of the Program

    • Your therapist will provide individualized strength based therapeutic interventions.
    • The collaboration and the merging of medical, psychological, social and educational needs of each individual is an essential component.
    • Input from the individuals we serve is a key in treating barriers and improving a client’s life mastery.
    • Your therapist will be trained and provide tools specific to the behavioral and emotional challenges of the at-risk population.

    You Have a Choice
    We recognize that you have a choice in selecting a mental health agency, and we thank you for choosing HEADS. We believe that your choice of HEADS was a good one, and that we will exceed your expectations.


    Access to Services
    HEADS receives referrals from Community Based Care Organizations, Schools, Child Protection Investigators, pastors, self-referrals, and daycare facilities. Business hours are Monday through Friday 8:00 am to 4:00 pm.  Our staff is available for evening and weekend appointments.  Services are provided in the home and school settings according to individual needs.

    About Our Staff
    At HEADS, we employ clinical staff with Master’s Degrees in Counseling or similar field.  We require at least 2 years of experience working with the population and provide ongoing training. A licensed therapist supervises all clinicians.

    Services Available
    At HEADS we provide individual, group and family counseling.  
    HEADS also offers psychiatric services, including medication management and psychiatric evaluations, performed by a qualified and experienced psychiatrist.

    Your Treatment Plan
    Your involvement in developing a mutually agreed-upon treatment plan is important to your care. You, and possibly those supporting your treatment (with your permission), will develop a treatment plan that outlines your goals and how to achieve them. You, your clinician, and other members of the treatment team will review and update your plan. You may request a copy of your plan. You and your clinician will meet to review your progress toward achieving your goals and objectives. You and your clinician may change and update your plan as appropriate during treatment.

    Feedback
    At HEADS, we consider you a partner in your treatment. To know if we are providing the best services, we ask for your evaluation and input. Your clinician will check with you periodically about this. However, we encourage your feedback at any time if you feel your care could be improved. We will periodically ask you to complete a client satisfaction survey. These surveys only take a few minutes to complete and give us valuable information regarding future service improvements.

    Americans with Disability Act
    If you have a special need or disability, please let us know so that we can provide a reasonable accommodation and ensure that you are comfortable while receiving quality client care. No otherwise qualified, disabled individual shall be solely, by reason of a disability, excluded from participation in or be denied benefits or subject to discrimination while a client of HEADS.

    Health and Safety
    HEADS is a smoke-free environment. Smoking and use of tobacco products is not permitted.

    To protect the safety and health of our clients, staff, and visitors, we prohibit the possession of any weapons or illegal substances on all properties of HEADS.

    Changing Your Clinician
    Clinically appropriate staff will be selected at intake. If you feel the service relationship is not helpful, you have a right to request a review and possible change of clinicians.

    The following are important documents and should be read carefully.  Please ask your therapist or call the HEADS office if you have questions about these documents.

    Client Rights and Responsibilities

    I HAVE THE RIGHT TO:

    • The RIGHT to be treated with dignity and respect.
    • The RIGHT to be free from physical, sexual and verbal abuse and neglect.
    • The RIGHT to an education.
    • The RIGHT to be involved in the service planning process and express opinions on the services received.
    • The RIGHT to receive services in an environment that is comfortable and clean.
    • The RIGHT to file complaints and grievances.
    • The RIGHT to privacy and confidentiality.
    • The RIGHT to access my record as allowable by HIPAA.
    • The RIGHT not to be discriminated against in the provision of services based on age, race, color, national origin, sexual orientation, religion, or disability.

    I HAVE THE RESPONSIBILITY TO:

    • Treat the staff and other participants in my treatment with dignity and respect.
    • Participate in treatment as outlined in my individual plan.
    • Obey the policies and procedures of attendance as described to me.

    Right to File a Grievance

    HEADS provide clients, their relatives, legal guardians, and other interested parties with the right to initiate a written complaint when there is concern with the services being provided, staff actions, or violations of rights. If you are unhappy with the services you are receiving you may discuss this with a particular staff member, or their immediate supervisor.  You may also share your concerns by filing a written complaint. 

    Depending on the nature of the complaint, there are various ways of responding. These could include investigations, interviews, and involvement from the Management Team. You will be notified the outcome of your grievance within 10 days of filing. If/when the complaint gets elevated you will be notified of the outcome within 10 days.  If you’re still not happy with the resolution of the complaint, you may notify your Case Manager for further investigation.

    See full Grievance Procedure at the end of the handbook.

    You Have the Right to Be Free of Abuse

    HEADS staff follows state and federal regulations regarding abuse and neglect reporting.  
    We will not knowingly abuse or neglect any client or fail to report suspected abuse or neglect.  Any client who feels they have been a victim of abuse, neglect or exploitation at our facility should call the Abuse Hotline at 1-800-962-2873

    HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT HIPAA PRIVACY NOTICE

    This notice describes how information about you may be used and disclosed and how you can get access to this information. 

    • Your confidential health care information may be released to other healthcare professionals within HEADS for the purpose of providing you with quality healthcare. This could include quality assurance and billing purposes.   
    • Your confidential healthcare information may be released to your insurance provider for the purpose of HEADS receiving payment for providing you with needed healthcare services.  
    • Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime, or domestic violence.  
    • Your confidential healthcare information may be released to other healthcare providers in the event you need emergency care.
    • Your confidential healthcare information may be released to a public health organization or federal organization in the event of a communicable disease.
    • Your confidential healthcare information may not be released for any other purpose that that which is identified in this notice.
    • Your confidential healthcare information may be released only after receiving written authorization from you.  You may revoke your permission to release confidential healthcare information at any time.
    • You may be contacted by HEADS to remind you of any appointments, healthcare treatment options, or other health services that may be of interest to you.
    • You may be contacted by HEADS for marketing the operations.
    • You have the right to restrict the use of your confidential healthcare information.  However, we may choose to refuse your restriction if it is in conflict with providing you with quality healthcare or in the event of an emergency situation.
    • You have the right to receive confidential communication about your health status.
    • You have the right to review and photocopy any/all portions of your healthcare information.
    • You have the right to make changes to your healthcare information.
    • You have the right to know who has accessed your confidential healthcare information.
    • You have the right to possess a copy of this Privacy Notice upon request. 
    • HEADS is required by law to protect the privacy of its clients.  It will keep confidential any and all client healthcare information and will provide clients with a list of duties or practices that protect confidential healthcare information. 
    • HEADS will abide by the terms of this notice.  We reserve the right to make changes to this notice and continue to maintain the confidentiality of all healthcare information.  Clients will receive a mailed copy of any changes to this notice within 60 days of making the change.
    • You have the right to complain to HEADS if you believe your rights to privacy have been violated.  If you feel your rights have been violated, please direct complaints to the HEADS compliance team.
    • All complaints will be investigated.  No personal issue will be raised for filing a complaint.

    GRIEVANCE PROCEDURE

    You have the right to let your concerns (grievances) about how you are being treated be known.

    You have a right to be told the method you can use to let your concerns (grievances) be known.  This written notice is a description of how to report grievances and complaints about services you receive from HEADS.  This notice should be given to you before you begin receiving services with HEADS.

    PROCEDURE:

    • You and/or your legal guardian are not limited in any way in the scope, content or frequency of your grievances.
    • You and/or your guardian may begin the grievance process by telling your Therapist what your complaint is either in person or in writing.  Your Therapist will give you a form to fill out to describe your concern.  Be sure to date it.
    • Your Therapist will review and address the complaint with the guidance of his or her supervisor.  If the complaint is about your Therapist, the supervisor will review the situation.
    • Your Therapist (or the supervisor) will provide you with a written response within ten working days of when you first let the complaint be known.
    • If you disagree with the response, you may take your complaint in writing to the Operations Manager. The Operations Manager will review the complaint and respond to you in writing within ten working days of receipt of your complaint.
    • If you disagree with what the Operations Manager decides, you may take your complaint in writing to the CEO.  The CEO will make the final decision and respond to you and your legal guardian in writing within ten working days.
    • Concerns the program staff may have about the possible inappropriate use of this grievance process will be reviewed by your TX Team (which will include a neutral person, such as a referring agency representative or a human rights representative) and will be addressed in your TX plan.

    What if I Have an
    Emergency or a Crisis?
    In the event of any life-threatening emergency, you should CALL 911 immediately. If someone is seriously hurt, is in grave danger, has attempted suicide, or there is a weapon involved, call 911 immediately.
    If you need to speak to someone during business hours, and your concern is not an emergency, call your primary clinician or the main office number.  If your call is received after business hours, the answering service will be able to take a message or connect you with an on-call staff member.

  • The nature and amount of information that may be disclosed, received, received and/or used by the parties pursuant to this authorization is as follows: (check yes or no for all areas indicated)
  • Initial and subsequent evaluations and assessments of my service needs by the following:

  • The purpose for disclosure, receipt and use of information authorized by me in this document is to enable the parties to evaluate my need, coordinate and provide services to me.

    I understand that generally my treatment, payment, enrollment or eligibility for benefits my not be conditioned upon my signing this authorization, but that in certain limited circumstances I may be denied treatment if I do not sign an authorization.

    I understand that the confidentiality of any information disclosed, received or used pursuant to this authorization is protected by law and will not be further disclosed by, or to and other party without my express written consent, or as otherwise permitted or required by applicable law.

    I further understand that I have the right to revoke this authorization in writing at any time, except to the extent that any authorized party has already taken action in reliance on it. If not previously revoked by me, this authorization will terminate as of the following date, event or condition, not to exceed one (1) year from the effective date (dated below).

    By my signature below I acknowledge that I have given my consent as indicated above freely, voluntarily and without coercion, and that I have been given a copy of (or the ability to print) this authorization, signed by me on the date shown below: