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.
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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 MissionTo 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
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 ServicesHEADS 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.
FeedbackAt 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 SafetyHEADS 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:
I HAVE THE RESPONSIBILITY TO:
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.
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.
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 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: