CPS Substance Abuse Intake Form

Purpose: Client acknowledgement of the information received from the Contractor describing the services offered, hours of operation, after-hours emergency contact, local community's behavioral health care crisis response information, and Client rights, programs rules, and privacy protections.

Contractor Directions: Complete this form and provide to the Client at the Client Orientation

Services to be Provided

Consists of private, face-to-face counseling between a Client and a counselor or therapist.

Consists of counseling provided simultaneously to at least two (2) unrelated individuals.

Consists of counseling provided simultaneously to two (2) or more members of a family. The family group may include parent/caregivers, children, and any other individuals who are close to or part of the family.

psychosocial assessment/ Substance abuse assessment/ BIPP assessment

Provider Contact Information

After-Hour Emergency Contact

Call 911 for Mental Health emergency

Information Provided

I acknowledge that Joseph Brown, LCSW-S has provided me with an orientation of the services that I will be receiving and has provided me with all of the information indicated on this form.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

CPS ZOOM SESSION RULES AND ATTENDANCE POLICY

These guidelines are necessary to maintain the integrity of our On Line therapeutic sessions. Groups must function as though clients and therapists are in an office setting.

1. Client is responsible to be in clear and stable WIFI connection a. If no clear connection is available in office sessions are required.
2. Client must be stationary - no driving or riding in a vehicle and no walking/moving around.
3. Client must be in a private location with no one else in the room/car.
4. Client must be fully and appropriately clothed during the session.
5. Client Must have face consistently visible in the camera - no cameras can be obstructed a. Backgrounds may not obstruct a clear view of the clients face.
6. Clients may not be admitted to group after 5 minutes late, after 5 minutes late session will be counted as No Show. The session will not be counted.
7. 2 or more No Show or late Canceled sessions may result in unsuccessful discharge.
8. Clients will be responsible to reschedule sessions with the office 10:00 am to 2:00 pm Mon-Thu. Therapists may approve make up sessions during group only-- Email, text or phone calls with the therapist will not be considered as notification.
9. Failed Drug screens must be reported and an individual session scheduled-No exceptions. Relapse/drug or alcohol use should be reported during group.
10. No Smoking or Vaping during Group
11. Noncompliance with any of the above rules will be counted as No Show and the session will not be considered complete.

I have read and understand that I may be not receive credit for Zoom sessions if I am not able to comply with these policies.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

By Signing I understand that No Show (less than 24 hour notice) Intake appointments will result in a $35 reschedule fee. It is my responsibility to be in a clear WIFI connection and that I may not be diving or riding in a vehicle.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

RELEASE and WAIVER
RELATING TO PROVIDING COUNSELING RECORDS AND COMMUNICATING PERSONAL HEALTH INFORMATION

in all capacities and in consideration of counseling and assessment services provided by JOSEPH BROWN LCSW-S, and any and all counselors and staff of Behavioral Solutions of Texas, LLC ( all collectively referred to as “Behavioral Solutions of Texas, LLC”), do hereby release them and hold them harmless from disclosing copies of and the content of my records, including my therapy and counseling records and assessments, as well as releasing them and holding them harmless for providing any oral or written communications relating to any information concerning my mental or emotional health, or substance abuse history or status.

Included in this release is my voluntary approval for the release by Behavioral Solutions of Texas, LLC of my personal health information described above, including to individuals or entities associated with state or federal agencies, such as the Department of State Health Services or Health and Human Services Commission or the Texas Department of Family and Protective Services. I understand that such information eligible to be disclosed encompasses all of my personal health information, including my substance abuse history, substance abuse issues, substance abuse-related information from the current CPS case, and results of drug tests.

I understand that a part of my care at Behavioral Solutions of Texas, LLC involves screening and assessment of my substance abuse status and what type of substance abuse services I may need. I specifically authorize Behavioral Solutions of Texas, LLC to disclose all of my personal health information as is needed to convey my history and current status, such disclosure being potentially made to Texas Department of Family and Protective Services, and those associated with them including attorneys, Department of State Health Services or Health and Human Services Commission, and to law enforcement, attorneys, and courts with jurisdiction over any matter where my personal health information would be relevant to their proceedings. I understand that there may be other individuals and entities to which the disclosure of my records and personal health information needs to occur, and I authorize Behavioral Solutions of Texas, LLC to make such disclosures as they deem necessary.

These individuals and entities are released of, from and against any and all demands, actions, liabilities, obligations, judgments, executions, causes of action or other claims (collectively called “claims”) in connection with any injuries or damages to myself allegedly caused by the alleged acts, omissions or other fault of the individuals and entity hereby released. This Agreement includes, but is not limited to, all matters relating to care and treatment provided at any time to me by Behavioral Solutions of Texas, LLC, JOSEPH BROWN LCSW-S and or his offices.

I am legally and mentally competent to execute this release agreement and have voluntarily done so.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.