Do you have custody papers?

    Would you like to be reminded of your appointment?

    When is the best time to call you?

    Do you have a Primary Care Doctor?

    Personal Medical History (Please select all that apply)

    Which of the categories best describes your current annual income? Please check the correct category




    Sexual Orientation

    Gender Identification

    Education Level

    Current Living Situation (Check all that Apply)



    Smoking/Tobacco Use


    Recreational Drug Use

    Are there any personal problems or concerns at home, work, or school you would like to discuss?

    Are there any cultural or religious concerns you have related to our delivery care?

    Are there any financial issues that directly impact your ability to manage your health?

    How often do you get the social and emotional support you need?

    The following is to be completed and initialed by the client or client’s legally authorized representative: I, , consent to mental health treatment for myself, or , for whom I am the parent or legally authorized representative. I understand that Serenity Mental Health (SMH) will share patient mental health information according to Federal and State law for treatment, payment and operations.

    I am aware that the type and extent of services I will receive will be determined following an assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. I am also aware that SMH is NOT a 24hr. crisis intervention provider and that should I be faced with a life-threatening emergency; I should call 9-1-1.

    Verbal consent for limited release of information may be necessary in special circumstances. I further understand that there are specific and limited exceptions to this confidentiality including the following:
    A. When there is risk of imminent danger to myself or to another person, the clinician is ethically bound to take necessary steps to prevent such danger.
    B. When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the clinician is legally required to take steps to protect them and to inform the proper authorities.
    C. When a valid court order is issued for medical records, the clinician and the agency are bound by law to comply with such requests.

    I understand that a range of mental health professionals, some of whom are in training, provide services with SMH. All professionals-in-training are supervised by licensed clinicians.

    I am fully aware that if I seek assistance from SMH in accessing community resources and I request transportation from any employee of SMH in efforts to meet my treatment needs, in extreme cases such as auto accident or other physical errors, I release SMH from any and all liabilities and assume all responsibility for my personal well-being and care.

    I am aware that SMH services will be billed to my insurance company and that there may be co-pays associated with these services. I authorize my insurance provider to pay SMH for all services rendered. I understand that it is my responsibility to sign the SMH consent log each time I, and/or my child, is picked up and transported outside of my home. Failure to sign this log will relieve SMH from any liability if you and your assigned worker do not communicate the location of or length of a session.

    I understand that if I have any concerns with my assigned SMH worker, or the services that I am
    receiving, that it is my responsibility to call the Quality Assurance Department at 702-815-1550 to report my concern.

    I have reviewed SMH’s HIPPA Policy and fully understand my rights If I have any questions regarding this consent form or about the services offered by SMH, I may discuss them with my therapist. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by SMH. I understand that I may stop treatment at any time.

    Grievance Procedure
    The purpose of the client grievance procedure is to allow you, as the client, the opportunity for recourse should there be unhappiness withthe servicesprovidedordecisionsmade.
    Upon initial complaint a program supervisor will conduct a preliminary investigation, and if deemed necessary by the program supervisor, or at your request; a meeting will be held with you, your worker from Serenity or SSH, and a program supervisor. The purpose of this meeting will be to resolve any dispute if possible. If the meeting is unsuccessful, Serenity/SSH will arrange for the Clinical Supervisor to hear and address your grievance. If you are not satisfiedwiththeresponsesgiven,youmaycontacttheStateof Nevadainordertodiscussyourconcern.
    Attendance Policy
    Therapy is designed to reduce and/or manage symptoms. Therefore, in order to achieve the full effectiveness of treatment, clients are expected to fully commit to therapy services on a consistent basis. By signing below, clients confirm their agreement to attend all scheduled appointments, and arrive at the appointments on time.
    If for whatever reason clients are unable to keep their scheduled appointment, they’re expected to give
    notification of the cancelation at least 1 day before the day of the appointment. “No Shows” for scheduled appointments could result in the termination of services. Termination of services will include medication management at Serenity and/or Silver State.
    If clients arrive more than 15 minutes after the session start time, the therapist has the right to cancel the remainder of that
    appointment. I understand that should I fail to comply with these terms, my services may be terminated.
    ePrescribe Program
    ePrescribing is way for doctors to send electronically an accurate, error free, and understandable prescription
    from the doctor's office to the pharmacy. The ePrescribe Program also includes:
    Formulary and benefit transactions - Gives the health care provider information about which drugs are covered by your drug benefit plan.
    Fill status notification - Allows the health care provider to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled.
    Medication history transactions - Provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues and to use that information to improve safety and quality. Medication history data can indicate: compliance with prescribed regimens; therapeutic interventions; drug-drug and drug-allergy interactions; adverse drug reactions, and duplicative therapy. The medication history information would include medications prescribed by your health care provider at Serenity/SSH as well as other health care providers involved in your care and may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, abortion{s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health Information.

    Weapon – Free Workplace Policy
    To ensure that Serenity & Silver State maintain a workplace safe and free of violence for all employees and clients, the company prohibits the possession or use of dangerous weapons on company property.
    Persons Covered
    All Serenity and Silver State workers and clients are subject to this provision, including contract workers and temporary employees as well as visitors and customers on company property. A license to carry the weapon on company property does not supersede company policy. Any employee and contractor in violation of this policy will be subject to disciplinary action, up to and including termination. Any client in violation of this policy will be asked to be taken off property and Serenity/Silver State has the rights to cut off all services.
    “Company property” is defined as all company-owned or leased buildings and surrounding areas such as sidewalks, walkways, driveways and parking lots under the company’s ownership or control. This policy applies to all company-owned or leased vehicles and all vehicles that come onto company property.
    “Dangerous weapons” include firearms, explosives, knives and other weapons that might be considered dangerous or that could cause harm. Employees are responsible for making sure that any item possessed by the employee is not prohibited by this policy.
    This policy is administered and enforced by Serenity and Silver State. Anyone with questions or concerns specific to this policy should contact any of the Serenity Directors or Silver State Administrators.

    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes standards to protect the privacy of healthcare information. Clients have certain rights to access and control how their healthcare information is used. Clients may request copies of their records, authorize others to receive copies of their records, request that corrections or changes be made their record, and request a list of when and to whom their health information has been shared.
    “Protected healthcare information” means healthcare information (including identifying information) collected from a client or received by a provider, another provider, a health plan, employer, or healthcare clearinghouse. It may include information about a client’s past, present, or future physical or mental health or condition, the provision of healthcare and payment for services.
    As a client, your alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without written consent unless otherwise provided for by the regulations.
    All protected healthcare information will be compiled in a client’s chart, which will be kept in locked cabinets in a locked room unless being utilized by staff members responsible for the provision of clinical services. At such times, staff members are responsible for maintaining confidentiality of information in the chart.
    Clients have the right to choose the healthcare/mental healthcare provider that will provide services. If at any time after selecting a provider, the client would like to change providers, HIPAA gives the client a right to do so. This is known and portability of services.
    Before Serenity and Silver State Health can disclose any healthcare information, they must obtain specific written consent to do so. Client has the right to revoke said written consent in writing at any time.
    Clients have the right to review and copy their chart maintained by SERENITY/SSH, except when that information is being compiled for use in civil, criminal, or administrative proceedings. Clients have the right to review this information after giving at least 24 hours oral or written notice. The client or their legal representative has the right to receive photocopies within 48 hours of notice.
    Client has the right, with some exceptions, to correct or change healthcare information maintained in their records. Clients may request and receive a list of disclosures of their health-related information created by SERENITY/SSH.
    HIPAA allows the exchange of protected information with Medicare, Medicaid, Nevada Check-Up and other private insurance companies for purpose of treatment, payment, and healthcare operations. Requests for healthcare information that will be utilized in determining eligibility for treatment or pre-authorization of payment do not require authorization from the patient/recipient for release. Federal Law permits the disclosure of your information without your written consent for the following circumstances:
     Toreportacrimepermittedonourpremisesoragainstourpersonnel  To medical personnel in a medical emergency
     For research, audit, or evaluations
     Toappropriateauthoritiestoreportsuspectedchildabuseorneglect
     As allowed by a courtorder

    PROTECTED HEALTH INFORMATION: In the course of treatment, information regarding your care may be created and/or received by us. Information which can be used to identify you and which relates to your past, present of future physical or mental condition, receipt of care or payment for care is considered protected information and is protected by federal and state law.
    Federal law imposes certain obligations and duties upon providers of services with respect to your protected information. Specifically, we are required to:
    • Provide you with notice of our legal duties and policies regarding the use and disclosure of your protected information;
    • Maintain the confidentiality of your protected information in accordance with state and federal law;
    • Honor your requested restrictions regarding the use and disclosure of your protected information, unless under the law we are authorized
    to release your protected information without your authorization.
    • Allow you to inspect and copy your protected information.
    • Act on your request to amend protected information, although we are not required to amend the protected information, within sixty (60)
    • Accommodate reasonable requeststo communicate protected informationbyalternative meansormethods;and
    • Abide by the terms of this notice.
    Generally, your protected information may be used and disclosed by us only with your express written authorization. This written authorization includes to whom the information may be disclosed, what information may be disclosed, and for what purpose. You may revoke this authorizationat anytime,althoughanyinformationreleasedpriortotherevocationmaybeusedasstatedontheconsent.
    There are some exceptions to this general rule. The following explains how we will use or disclose your protected information without your authorization:
    • Treatment Purposes: We may use or disclose your protected information for treatment purposes to doctors, nurses, hospitals, for instance, in order to facilitate your treatment.
    • Payment Purposes: Your protected information may be used or disclosed to your insurance company, for instance, for payment purposes as it may be necessary to disclose this information so that we may properly receive payment for treatment and services provided.
    • Health Care Operations: Your protected information may be used or disclosed for health care operations. For example, record review relatedtoquality assuranceandimprovement activities.
    • Compliance and Quality Assurance: We may release your protected information to another individual or entity covered by the HIPPA privacy regulations that has a relationship with you for fraud and abuse detection or compliance purposes, quality assessment and improvement activities,or review,evaluationor trainingofprofessionalsorstudents.
    • Oversight Activities: Your protected information may be used or disclosed to an oversight agency for activities authorized by law. Examplesofoversightactivitiesincludeaudits,investigations,andinspections.Inmostcases,theoversightactivitywillbeforthe purpose of overseeing services and agency compliancewithcertain laws and regulations.
    • Judicial andAdministrativeProceedings:If youareinvolvedinalawsuitorother administrative proceeding,we may release your protectedinformationinresponsetoacourtoradministrativeorder.Wemayalsoreleaseprotectedinformationpursuanttoa subpoenaor discoveryrequest,butonlyifeffortshavebeenmadebytherequestortoprovideyouwithnoticeoftherequest andyouhave failedtoobjectortheobjectionwasresolvedinfavordisclosure,orinthealternative,therequestorhasobtaineda protectiveorder protecting therequested information.
    • Law Enforcement: We may release your protected information to law enforcement officials when required or permitted by federal or state law to do so.
    • Emergency Circumstances: Protected information may be disclosed to personnel who have a need for information about a client, such as for the purpose of treating a medical or mental condition which poses an immediate threat to the health and safety of any individual or the public and which requires immediate intervention.
    • Individuals Involved in Your Care: We may give out your protected information to a friend or family member who is helping with your careorwithpaymentforyourcare.However,priortosharingyourprotectedinformationinthisinstancewewillfirst attempttoobtainyour verbalorwrittenconsent.Anexampleofwhenobtainingsuchconsentwouldnotbefeasiblewouldbeif youareinvolvedin a serious accidentandunavailabletogiveyourconsentanditisnecessaryforustospeakwithyouremergency contactorother responsibleparty.
    • MandatoryReportingofChild Abuse/DependentAdultAbuse:Serenityand Silver State’sstaffaremandatoryreportersofchild abuse and dependent adult abuse. In the event that there is reason to suspect that child abuse or dependent adult abuse has occurred, your protectedinformationmaybedisclosedasrequiredbylaw.
    • AsAuthorizedbyLaw:Wewilldiscloseyourprotectedinformationforreasonsnotdescribedabovewhenrequiredbylawtodoso.
    • More Stringent Laws: Some of your protected information may be subject to other laws and regulations and are afforded
    greater protectionthatwhatisoutlinedinthisNotice.Forinstance,HIV/AIDS,substanceabuse,andmentalhealthinformationisoften given more protection. In the event your protectedinformationisaffordedgreaterprotectionunderfederalorstate law, we will comply with the applicablelaw.

    Federal law grants you certain rights with respect to your protected information. Specifically, you have the right to:
    • Receivenoticeofourpoliciesandproceduresusedtoprotectyourprotectedinformation;
    • Request that certain uses and disclosures of your protected information be restricted, provided, however, if we release the information
    without your consent or authorization, we have the right to refuse your request;
    • Access to your protected information be amended, although we are not required to grant your request;
    • Obtain an accounting of certain disclosures by us of your protected information for the past six (6) years;
    • Revoke any prior authorizations for use or disclosure of protected information, except to the extent that action has already been taken; and
    • Request that communications of your protected information are done by alternative means or at alternative locations.
    This notice has been provided to you as a summary or how we will use your protected information and what your rights with respect to your protectedinformationare.Ifyouhaveanyquestionsorwouldlikemoreinformationregardingyourprotectedinformation,please contactyourdirect workerorthesupervisoroftheprograminwhichyouparticipate.Ifyoubelieveyourprivacyrightshavebeenviolated,youmay fileacomplaintwithourofficebycontactingyourdirectworkerorthesupervisororthe programinwhichyouparticipate.Heorshewill provideyouwithspecific informationregardingtheagency’sgrievancepolicy.YoumayalsofileacomplaintwiththeSecretaryofHealthand Human Services. There will be no retaliation for the filing of a complaint.
    Client Rights
    The following applies to all clients of our counseling and mental health services.
    Theclient astheright:
    A) Tochooseahealthcareproviderthatisapprovedbytheirinsuranceprovidertoprovideservices.
    B) Tobetreatedwithdignity,considerationandrespectatalltimes.
    C) To expect quality service providedbyconcerned,trained,professionalandcompetent staff
    D) To expect complete confidentiality within the limits of the law, and to be informed about the legal exceptions to confidentiality, and to
    expect that no information will be released without the client’s knowledge and written consent.
    E) To a clear working contract in which business items, such as time of sessions, payment plans/fees, absences, access, emergency
    procedures, and third-party reimbursement procedures are discussed.
    F) To a clear statement of the purposes, goals, techniques, rules of procedure and limitations, as well as the potential dangers of the services
    tobeperformed,andallotherinformationrelatedtoorlikelytoaffecttheongoingmentalhealthcounseling relationship. G) To appropriate information regarding the mental health counselor’s education, training, skills, license and practice limitations and to
    requestandreceive referralstootherclinicians when appropriate.
    H) Tofull,knowledgeable,andresponsibleparticipationintheongoingtreatmentplantothemaximum extent feasible.
    I) Toobtaininformationaboutcaserecordsandtohavethisinformationexplainedclearlyanddirectly.
    J) To request informationand/orconsultation regarding the conductandprogressoftherapy:
    K) Torefuseanyrecommendedservicesandtobeadvisedoftheconsequencesofthisaction.
    L) Toasafeenvironmentfreeofemotional,physicalandsexualabuse.
    M) To a client grievance procedure, including requests for consultation and/or mediation, and to file a complaint with the mental health
    counselor’s supervisor, and/or the appropriate credentialing body; and N) Toaclearlydefinedendingprocess,andtodiscontinuetherapyatanytime.
    Adapted from AMHCA Code of Ethics 2002

    Patient/Client Rights/ Acknowledgment of Privacy Practices
    I, acknowledge that I have received a copy of the Notice of Privacy Practices and Client Rights which summarizes thewaysmyidentifiable health informationmay beused and disclosedbythis provider,and it alsostatesmyrights with respect to my medical information as provided by 42 CFR. Part 2 and 45 CFR. I understand this provider has the right to revise these information practices andtoamendtheNoticeofPrivacyPractices. Ihavebeen informed that in the event this provider revises its information practices, a revised Notice of Privacy Practices will be posted atSerenity’s and Silver State’s locations.The Serenity locations are:1901S. JonesBlvd LasVegas,NV89146/ 2280 EastCalvadaSuite#301-Pahrump,NV89048/755N.RoopStSte.101CarsonCity,NV 89701.Silver State Health’s locations are: 2255 Renaissance Dr, Las Vegas, NV 89119 and 2965 S Jones Blvd LV, NV 89146. I mayobtain a current form at any time from any Serenity or SSH location.
    It is our duty, as mandatory reporters, to immediately report any suspected child abuse to Child Protective Services. The worker shall report suspected abuse orally to the CPS, followed by a written report to CPS within 48 hours after such oral report. The worker shall also make an oral reporttoanappropriatelawenforcementagencyiftheworkerbelievesthatimmediateprotectionofthechildisadvisable.
    Type of abuse
    1. Physical Abuse
    2. Mental Injury
    3. Sexual Abuse
    4. Denial of Critical Care
    5. Child Prostitution
    6. Presence Of Illegal Drugs In The Body Of A Child
    7. Manufacture Or Possession Of Dangerous Substances In The Presence Of The Child 8. Bestiality In The Presence Of A Minor
    9. CohabitationWithA Registered Sex Offender
    Yourrecordscannotbereleasedtoanyotherindividualwithoutyourwrittenconsent. However,certaininformationmaybereleasedwithoutyour authorizationunder thefollowinglegalcircumstance:WhenJuvenileCourtisinvolved;recordsmaybe sharedwithJuvenileCourtOfficers. Information about a child may be shared with the child’s Guardian Ad Litem. Information may also be shared in the event of a legitimate subpoenaforcourtappearance,intheeventofamedicalemergency,orwhenthereceiptofinformationsuggeststhatchildabuseor neglect has occurred. SERENITY/SSH is legally obligated to report any such information to CPS under circumstances in which there exists a danger to the child or others.
    X X
    These policies have been explained to me in my own language.
    Patient / Client /Conservator or Legal Guardian* Date:
    Power of Attorney (if applicable) * Date: Witness (Only required if client signs with a mark) Date:
    * Verification of representative status required.
    Signature covers:
    Patient/Client Rights/ HIPAA Practices/Consent for Treatment/Weapons Policy/Grievance Policy/Attendance Policy/E-Scribe

    Authorization to Release Protected Confidential Information
    Phone #:
    This release of information is active from
    *Client has the right to revoke at any time, revoke date
    until .
    , Client signature
    I authorize Serenity Mental Health/Silver State Health to information: the following

    My signature authorizes the release of these records through facsimile transmission (FAX). I understand and agree that should the records be inadvertently transmitted to an unauthorized recipient, through no fault of the sender, I hereby waive any claim against the sender. I agree to hold the sender harmless from any and all responsibility for damages, if any, arising from the faulty transmission.
    This authorization is in effect until termination of treatment or 12 months from the above date. I understand that I may change my mind at any time and revoke this authorization by notifying Serenity Mental Health/Silver State Health in writing. I understand that changing my mind or refusing to sign this form will not affect my treatment. I understand that I have the right to inspect or copy any information disclosed under this authorization. I understand that once my health information is disclosed to the recipient, Serenity Mental Health/Silver State Health cannot guarantee that the recipient will not disclose the health information to a third party or as required by law. I have read and understand this authorization and had a chance to ask questions about the disclosure of the health information. I authorize Serenity Mental Health to disclose my health information in the manner described above.
    This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
    As a client you agree that patient identifying information disclosed pursuant to an audit or evaluation may be disclosed only back to the program from which it was obtained and used only to carry out an audit or evaluation or to investigate or prosecute criminal or other activities as authorized by a court order entered under § 2.66 of the drug treatment confidentiality records contained in 42 C.F.R. Part 2. If I copy or remove any records containing patient identifying information, I also agree to maintain the patient identifying information in accordance with the security requirements contained in 42 C.F.R. § 2.16 and to destroy all patient identifying information upon completion of the audit or evaluation.
    Patient Signature: Parent/Guardian Signature:
    *1901 S Jones-Las Vegas NV 89146 * Ph. 702-815-1550
    Fax 702-815-1554
    * 2280 East Calvada Suite #301-Pahrump, NV 89048* Ph. 775-751-5211
    Fax 775-7516176
    Date: Date:
    * 755 N. Roop St. Ste 101-Carson City, NV 89701* Ph. 775-841-6050
    Fax 775-841-6053