Intake Form


    Please complete this form in order for us to provide you with the highest quality of care and service.





    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?








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    Personal Medical History (Please select all that apply)









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    Social/Cultural History


    Under $10,000$10,000 - 14,999$15,000 - 19,999$20,000 - 29,999$30,000 - 49,999$50,000 - 79,000Over $80,000

    American Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderBlack or African AmericanWhiteHispanic Other RaceOther Pacific IslanderUnreported/Refused to Report

    Hispanic or LatinoNot Hispanic or LatinoRefused to Report


    NoYes

    StraightGay or LesbianBisexualSomething ElseDon't KnowChoose Not to Disclose

    MaleFemaleTransgender Male to FemaleTransgender Female to MaleOtherChoose Not to Disclose

    ElementaryHigh SchoolVocationalCollegeGraduate/Professional

    Current Living Situation (Check all that Apply)


    YesNo


    YesNo


    CurrentPastNever



    Alcohol

    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?


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    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.

    Please Initial Below:

    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.

    Please Initial Below:

    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.

    Please Initial Below:

    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.

    Please Initial Below:

    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.

    Please Initial Below:

    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.

    Please Initial Below:

    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.

    Please Initial Below:

    I have reviewed SMH’s HIPAA 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.

    Please Initial Below:


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    Grievance Procedure

    The purpose of the client grievance procedure is to allow you, as the client, the opportunity for recourse should there be unhappiness with the services provided or decisions made.

    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 satisfied with the responses given, you may contact the State of Nevada in order to discuss your concern.

    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.


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    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.

    Definitions

    “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.
    Enforcement

    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.


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    HIPAA

    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:
    • To report a crime permitted on our premises or against our personnel
    • To medical personnel in a medical emergency
    • For research, audit, or evaluations
    • To appropriate authorities to report suspected child abuse or neglect
    • As allowed by a court order


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    NOTICE OF PRIVACY PRACTICES

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    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) days and notify you of any delay which would require us to extend the deadline by the permitted thirty (30) day extension.
    • Accommodate reasonable requests to communicate protected information by alternative means or methods; and
    • Abide by the terms of this notice.

    HOW YOUR PROTECTED INFORMATION MAY BE USED AND DISCLOSED

    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 authorization at anytime, although any information released prior to the revocation may be used as stated on the consent.
    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 related to quality assurance and improvement activities.
    • Compliance and Quality Assurance: We may release your protected information to another individual or entity covered by the HIPAA privacy regulations that has a relationship with you for fraud and abuse detection or compliance purposes, quality assessment and improvement activities, or review, evaluation or training of professionals or students.
    • Oversight Activities: Your protected information may be used or disclosed to an oversight agency for activities authorized by law. Examples of oversight activities include audits, investigations, and inspections. In most cases, the oversight activity will be for the purpose of overseeing services and agency compliance with certain laws and regulations.
    • Judicial and Administrative Proceedings: If you are involved in a lawsuit or other administrative proceeding, we may release your protected information in response to a court or administrative order. We may also release protected information pursuant to a subpoena or discovery request, but only if efforts have been made by the requestor to provide you with notice of the request and you have failed to object or the objection was resolved in favor disclosure, or in the alternative, the requestor has obtained a protective order protecting the requested 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.

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    • Individuals Involved in Your Care: We may give out your protected information to a friend or family member who is helping with your care or with payment for your care. However, prior to sharing your protected information in this instance we will first attempt to obtain your verbal or written consent. An example of when obtaining such consent would not be feasible would be if you are involved in a serious accident and unavailable to give your consent and it is necessary for us to speak with your emergency contact or other responsible party.
    • Mandatory Reporting of Child Abuse/Dependent Adult Abuse: Serenity and Silver State’s staff are mandatory reporters of child abuse and dependent adult abuse. In the event that there is reason to suspect that child abuse or dependent adult abuse has occurred, your protected information may be dis closed as required by law.
    • AsAuthorizedbyLaw: We will disclose your protected information for reasons not described above when required by law to do so.
    • More Stringent Laws: Some of your protected information may be subject to other laws and regulations and are afforded greater protection that what is outlined in this Notice. For instance, HIV/AIDS, substance abuse, and mental health information is often given more protection. In the event your protected information is afforded greater protection under federal or state law, we will comply with the applicable law.


    YOUR RIGHTS

    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.

    IMPORTANT CONTACT INFORMATION

    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 protected information are. If you have any questions or would like more information regarding your protected information, please contact your direct worker or the supervisor of the program in which you participate. If you believe your privacy rights have been violated, you may file a complaint with our office by contacting your direct worker or the supervisor or the program in which you participate. He or she will provide you with specific information regarding the agency’s grievance policy. You may also file a complaint with the Secretary of Health and 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.

    The client as the right:

    A) To choose a health care provider that is approved by their insurance provider to provide services.
    B) To be treated with dignity, consideration and respect at all times.
    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 to be performed, and all other information related to or likely to affect the ongoing mental health counseling relationship.
    G) To appropriate information regarding the mental health counselor’s education, training, skills, license and practice limitations and to
    request and receive referrals to other clinicians when appropriate.
    H) To full, knowledgeable, and responsible participation in the ongoing treatment plan to the maximum extent feasible.
    I) To obtain information about case records and to have this information explained clearly and directly.
    J) To request information and/or consultation regarding the conduct and progress of therapy:
    K) To refuse any recommended services and to be advised of the consequences of this action.
    L) To a safe environment free of emotional, physical and sexual abuse.
    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) To a clearly defined ending process, and to discontinue therapy at any time.

    Adapted from AMHCA Code of Ethics 2002


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    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 the ways my identifiable health information may be used and disclosed by this provider, and it also states my rights 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 and to amend the Notice of Privacy Practices. I have been informed that in the event this provider revises its information practices, a revised Notice of Privacy Practices will be posted at Serenity’s and Silver State’s locations. The Serenity locations are:

    1901 S. Jones Blvd
    LasVegas, NV 89146

    2280 East Calvada
    Suite #301
    Pahrump, NV 89048

    755N.Roop St
    Ste.101
    Carson City, NV 89701

    Silver State Health’s locations are:

    2255 Renaissance Dr
    Las Vegas, NV 89119

    2965 S Jones Blvd
    Las Vegas, NV 89146

    I may obtain a current form at any time from any Serenity or SSH location.

    CHILD/DEPENDENT ADULT ABUSE REPORTING POLICY

    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 report to an appropriate law enforcement agency if the worker believes that immediate protection of the child is advisable.

    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. Cohabitation With A Registered Sex Offender

    Your records cannot be released to any other individual without your written consent. However, certain information may be released without your authorization under the following legal circumstance: When Juvenile Court is involved; records may be shared with Juvenile Court Officers. 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 subpoena for court appearance, in the event of a medical emergency, or when the receipt of information suggests that child abuse or 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.

    These policies have been explained to me in my own language.

    Signature covers:
    Patient/Client Rights/ HIPAA Practices/Consent for Treatment/Weapons Policy/Grievance Policy/Attendance Policy/E-Scribe


    * Verification of representative status required.

    Please Sign Below: