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Demographic Information

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    I hereby grant permission to Just I Life Services LLC and associates to provide routine evaluation, treatment & training services as may be deemed necessary or advisable for my diagnosis and/or care plan. I understand that this consent shall remain valid until I withdraw consent. I understand that all information gathered in the course of my treatment at Just 1 Life Services LLC is confidential. However, information may be released without my consent in cases of a medical emergency, abuse or neglect, court order, insurance billing claims requirements, audit and program evaluation, and where otherwise permitted by state or federal law. Additionally, l understand that by signing this consent I am giving permission for ADHS to access my information and records maintained by Just 1 Life Services LLC and/or its subcontracted providers concerning the provision of covered services.

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    Payment / Insurance Information

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      Name of Training Program: Just 1 Life - Peer Support Training program / by Justin D.L. Harvey

      Completing this interview and meeting all requirements of this application does not guarantee admission into a Peer Support Employment Training Program (PSETP). Training programs may have other requirements such as assessments, referrals, additional forms, background checks and/or tuition which must be completed or paid prior to admission.

      Do you understand this and have you satisfied all the requirements of the program to which you are applying?

      Are you applying to this training program because you intend to practice peer support and deliver peer support services as a PRSS?

      Completion of a Peer Support Employment Training Program is not a guarantee of employment.

      Do you understand and agree to this?

      Self-identification as a person with lived experiences of behavioral health conditions is a requirement to receive a PRSS credential. Upon completion of this program your name, the name of the training program, date of graduation and current employer (if applicable) will be transmitted to AHCCCS as specified in AMPM Policy 963.

      Do you understand and agree to this?

      This Peer Support Employment Training is intended to prepare you to practice and deliver peer support services in the AHCCCS (Medicaid) programs.

      If nothing about that concerns you type "nothing".
      If nothing about that concerns you type "nothing".

      A Peer & Recovery Support Specialist (PRSS) is an individual who has lived experience of mental health conditions, substance use and/or other traumas resulting in emotional distress and significant life disruption, for which they have received treatment and or support for; and they can now demonstrate and share the experience and self-directed recovery, including knowledge of approaches to support the recovery of others.

      Can you willingly self-identify to others as having lived experience of mental health conditions, substance use and/or other traumas resulting in emotional distress and significant life disruption, for which you have sought support?

      Are you actively engaged in your own recovery, healing and wellness practices?

      Are you willing to share these lived experiences, when appropriate, for purposes of education, role modeling and providing hope to others about the reality of recovery?

      Are you willing to share what you have had to overcome to get where you are in your recovery?

      Are you willing to share what having “lived experience” means to you?

      Are you willing to share some of the beliefs and values you have, or have developed, which help to strengthen your recovery?

      The training program requires complete attendance for the duration of the training.

      If accepted to this program, can you commit to the attendance requirements?

      Are there any barriers which may keep you from attending the entire training (e.g. childcare, work schedule, transportation)?

      The training is highly interactive and requires activities involving small group work, role-playing, and reading aloud to the class.

      Are you comfortable with this kind of participation?

      As part of the training you will be asked to participate in discussions, role-plays, and to share your personal story of recovery in front of the class.

      Are you comfortable with this kind of participation?

      During the training you will listen to the recovery stories of others. Sometimes these stories may be uncomfortable to hear.

      Are you willing to communicate any discomfort to the trainers if this were to happen?

      If nothing about that concerns you type "nothing".
      If no special accommodations are needed type "no".
      Type your first name, middle initial and last name here.


      I hereby grant Just 1 Life Services LLC and its Associates permission to take my photograph and to save those photographs for use in identifying me or any other lawful purpose, including, saving it to my medical health record profile. As part of the electronic health record your photo will remain confidential and private and will not be used for any advertising or commercial use.

      Type your first name, middle initial and last name here.


      I hereby consent to participate in Telehealth with, Just 1 Life Services LLC and its clinicians, as part of my psychotherapy. I understand that Telehealth is the practice of delivering clinical health care services via technology-assisted media or other electronic means between a practitioner and a client who are located in two different locations.

      I understand the following with respect to telehealth health:

      • I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
      • I understand that there are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
      • I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
      • I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to Telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of a child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding)
      • I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that Telehealth services are not appropriate and a higher level of care is required.
      • I understand that during a Telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me to discuss it since we may have to re-schedule.
      • I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.

      In Case of an Emergency While in Telehealth Session

      If you have a mental health emergency, I encourage you not to wait for communication back from me, but do one or more of the following:

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      Just 1 Life Services LLC supports and protects the fundamental human, civil, constitutional, and statutory rights of each patient it serves. In recognition of this belief, the following patient rights are affirmed. You have the right.

      1. To be treated with dignity, respect, and consideration;

      2. Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, diagnosis, or source of payment;

      3. To receive treatment that; Supports and respects your individuality, choices, strengths, and abilities.b. Supports your personal liberty and only restricts your personal liberty according to a court order; by your consent; or as permitted in A.A.C. R9-20 to comply with treatment needs; and c. c. Is provided in the least restrictive environment that meets your treatment needs;

      4. Not to be prevented or impeded from exercising your civil rights unless you have been adjudicated incompetent or a court of competent jurisdiction has found that you are unable to exercise a specific right or category of rights;

      5. To submit grievances to agency staff members and complaints to outside entities and other individuals without constraint or retaliation;

      6. To seek, speak to, and be assisted by legal counsel of your choice, at your expense;

      7. To receive assistance from a family member, designated representative, or other individuals in understanding, protecting, or exercising your rights;

      8. If enrolled by ADHS/DBHS, Mercy Maricopa Integrated Care, or Just I Life Services LLC as an individual who is seriously mentally ill, to receive assistance from human rights advocates provided by ADHS/DBHS or the ADHS/DBHS's designee in understanding, protecting, or exercising your rights;

      9. To have your information and records kept confidential and released only as permitted under A.A.C R9 20-211 (A) (3) and (B)

      10. To privacy in treatment, including the right not to be fingerprinted, photographed, or recorded without consent, except for photographing for identification and administrative purposes; b. For a patient receiving treatment according to A.R.S.§36, Chapter 37;

      11. To review, upon written request, your own record during the agency's hours of operation or at a time.

      12. To review the following at the agency or at ADHS/DBHS: a. A.A.C. R9-20; b. The report of the most recent inspection of the premises conducted by ADHS/DBHS; c. A plan of correction in effect as required by ADHS/DBHS; d. If the licensee has submitted a report of inspection by a nationally recognized accreditation agency in lieu of having an inspection conducted by ADHS/DBHS, the most recent report of an inspection conducted by the nationally recognized accreditation agency; e. If the licensee has submitted a report of inspection by a nationally recognized accreditation agency in lieu of having an inspection conducted by the ADHS/DBHS, a plan of correction in effect as required by the nationally recognized accreditation agency;

      13. To be informed of all fees that you are required to pay and of the agency's refund policies and procedures before receiving behavioral health service except for crisis services.

      14. To receive a verbal explanation of the patient's condition and a proposed treatment, including the intended outcome, the nature of the proposed treatment, procedures involved in the proposed treatment, risks or side effects from the proposed treatment, and alternatives to the proposed treatment;

      15. To be offered or referred for the treatment specified in your treatment plan;

      16. To receive a referral to another agency if the agency is unable to provide a behavioral health service that you request or that is indicated in your treatment plan;

      17. To give general consent and, if applicable, informed consent to treatment, refuse treatment or withdraw general or informed consent to treatment, unless the treatment is ordered by a court according to A .R.S. Title 36, Chapter 5, is necessary to save the patient's life or physical health, or is provided according to A.R.S. § 36-512;

      18. To be free from; a. Abuse; b. Neglect; c. Exploitation; Coercion; e. Manipulation; f. Retaliation for submitting a complaint to ADHS/DBHS or another entity. Discharge or transfer, or threat of discharge or transfer, for reasons unrelated to your treatment needs. h. Treatment that involves the denial of 1. Food, 2. The opportunity to sleep, or 3. The opportunity to use the toilet: and restraint or seclusion, of any form used as a means of coercion, discipline, convenience, or retaliation.

      19. To participate or, if applicable, to have your parent, guardian, custodian or agent participate in treatment decisions and in the development and periodic review and revision of your, written treatment plan;

      20. To control your own finances except, when: You are under guardianship or conservatorship or have a representative payee; or b. Otherwise ordered by a court of competent jurisdiction;

      21. To participate or refuse to participate in religious activities;

      22. To refuse to perform labor for an agency, except for housekeeping activities and activities to maintain health and personal hygiene;

      23. To be compensated according to state and federal law for labor that primarily benefits the agency and that is not part of your treatment plan;

      24. To participate or refuse to participate in research or experimental treatment;

      25. To give informed consent in writing, refuse to give informed consent, or withdraw informed consent to participate in research or in treatment that is not professionally recognized treatment:

      26. To refuse to acknowledge gratitude to the agency through, written statements, other media, or speaking engagements al public gatherings;

      27. To receive behavioral health services in a smoke-free facility, although smoking may be permitted outside the facility, according to the agency's policies and procedures;

      28. If receiving treatment in a residential agency or an inpatient treatment program: If assigned to share a bedroom, and to assigned after considering your: 1. Age 2. Gender 3. Development Level 4. Behavioral health issue 5. Treatment needs. Need for group support, independence, and privacy; To associate with individuals of your choice, receive visitors, and take telephone calls during the hours established by the licensee and conspicuously posted in the facility. unless. The medical director or clinical director determines and documents a specific treatment purpose that justifies waiving this right; and 2. You are informed of the reasons why this right is being waived and our right to submit a grievance regarding this treatment decision. To privacy in correspondence, communication, visitation. financial affairs, and personal hygiene. unless; 1. The medical director or clinical director determines and documents a specific treatment purpose that justifies, waiving this right; and, you are informed of the reason, why this right is being waived and your right to submit a grievance regarding this treatment decision. To send and receive uncensored and unopened mail, unless restricted by Court Order. To maintain, display, and use personal belongings, including clothing unless restricted by court order or to protect the safety of the patient and/or others according to A .R.S.§36-507 (5) and as documented in the patient medical record. To be provided storage space, capable of being locked, on the premises while you receive treatment. To be provided with meals to meet your nutritional needs, with consideration for your preferences. To be assisted in obtaining clean, seasonably appropriate clothing that is good repair and selected and owned by you; To be provided Access to medical services, including family planning to maintain your health safety or welfare. To have opportunities for social contact and daily social, recreational. or rehabilitative activities; To be informed of the requirements necessary for your discharge or transfer to a less restrictive physical environment; To receive, at the time of discharge or transfer, recommendations for any treatment needed.

      Type your first name, middle initial and last name here.



      I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to make sure that protected health information (“PHI”) that identifies you is kept private.

      Give you this notice of my legal duties and privacy practices with respect to health information.

      Follow the terms of the notice that is currently in effect.

      I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

      II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures, I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories. For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have a direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in the diagnosis and treatment of your mental health condition. Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another. Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful processes by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

      III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For my use in defending myself in legal proceedings instituted by you.d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA required by law and the use or disclosure is limited to the requirements of such law.f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes required by a coroner who is performing duties authorized by law.h. Required to help avert a serious threat to the health and safety of others. 2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

      IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons: 1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. 2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.3. For health oversight activities, including audits and investigations.4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain authorization from you before doing so.5. For law enforcement purposes, including reporting crimes occurring on my premises. 6. To coroners or medical examiners, when such individuals are performing duties authorized by law. 7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.9. For workers' compensation purposes. Although my preference is to obtain authorization from you, I may provide your PHI in order to comply with workers' compensation laws.10. Appointment reminders and health-related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

      V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT. 1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or another person that you indicate is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

      VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI: 1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full. 3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request. 6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request. 7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.


      Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information.


      General Information

      The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me.

      Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

      The Therapeutic Process

      You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.


      The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

      1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

      2. If a client threatens grave bodily harm or death to another person.

      3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

      4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

      5. Suspected neglect of the parties named in items #3 and # 4.

      6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

      7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

      Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

      If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.


      Understanding that these records may contain information pertaining to substance abuse/use and/or HIV/Hep C, or other communicable disease testing or treatment, and for the purposes of coordinating treatment and in case of an emergency, I authorize Just 1 Life Services LLC and Associates to use and disclose to my above listed emergency contact my enrollment and discharge information and any additional information indicated by checked boxes below;

      I understand that my records are protected under Federal and State Confidentiality Regulations and that my records cannot be disclosed without my written consent except otherwise provided for in the Federal and State Regulations, see current "HIPAA Form" and 'Consent for Treatment Form." I understand that I may revoke this consent, in writing, at any time, except to the extent that action has already been taken in compliance with this agreement. This consent shall expire automatically one year' after the patient's relationship with either party mentioned in this agreement is terminated or when written request is presented ending authorization.

      EXPIRES 1 year from today's date.

      Your information will be encrypted.