Admission Packet

Informed Consent for Treatment

I am voluntarily consenting to participate in treatment at STAR Council as a client in need of substance use counseling and education. The treatment is provided by Licensed Counselors.
Client Number: *
Provided by Counselor
Name: (Last Name, First Name)
Include comma after last name.
Counselor Completing the screening
Select Counselor from the list:
Diagnosis Given
Severity
It is Recommended that I attend:
The expected benefits of treatment are:
- Maintenance of sobriety
- Improved marital/couple relationship
- Decreased stress/anxiety
- Improved relationships at work/school
- Decreased financial stress Improved job/school performance
- Improved family relationships Improved peer relationships
The probable mental and physical health consequences of not consenting may include:
- Mental deterioration
- Physical deterioration
- Loss of work/school opportunities
- Financial stress
- Legal complications
The possible side effects and risks associated with treatment include:
- Loss of family relationships
- Loss of peer relationships
- Loss of marital/couple relationship
- Intense emotional reactions
- Increased anxiety
Alternatives to treatment at STAR Council include:
- MHMR
- Inpatient detoxification
- 12 -step program or other programs
- Hospitalization
- Residential care
- No treatment
I have been briefed and understand the Client Grievance Procedures and have received a copy.

I have been briefed and understand the Client Bill of Rights and received a copy.

I have been briefed on Program Rules and have received a copy.

I have been briefed on violations that could lead to disciplinary action and discharge and have received a copy.

I have been briefed on consequences or searches used to enforce program rules and have received a copy.

I have been briefed on estimated daily charges including an explanation of any charges that may be billed separately to a third party or to myself based on the evaluation of my financial resources.

I have been briefed on STAR Council’s treatment process and the opportunities for families to be involved in treatment.

I consent to participate in the follow-up program for up to one year after my discharge. In the event that the agency is not able to contact me directly, I give my consent for you to contact the Permanent Contact listed on the Client Profile in order to give the agency the necessary information about my status.
Today's Date *

Month Day Year
Date
Signature *

Clear

Client Bill of Rights and Responsibilities
Client Number: *
Provided by Counselor
Name (Last Name, First Name)
Include comma after last name.
Clients of STAR Council on Substance Abuse have these rights:

1. You have the right to accept or refuse treatment after receiving this explanation.

2. If you agree to treatment or medication, you have the right to change your mind at any time (unless specifically restricted by law

3. You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your personal needs.

4. You have the right to be free from abuse, neglect, and exploitation.

5. You have the right to be treated with dignity and respect.

6. You have the right to appropriate treatment in the least restrictive setting available that meets your needs.

7. You have the right to be told about the program's rules and regulations before you are admitted, including, without limitation, the rules and policies related to restraints and seclusion. Your legally authorized representative, if any, also has the right to be and shall be notified of the rules and policies related to restraints and seclusion.

8. You have the right to be told before admission:

(A) The condition to be treated;

(B) The proposed treatment;

(C) The risks, benefits, and side effects of all proposed treatment and medication;

(D) The probable health and mental health consequences of refusing treatment;

(E) Other treatments that are available and which ones, if any, might be appropriate for you; and

(F) The expected length of stay.

9. You have the right to a treatment plan designed to meet your needs, and you have the right to take part in developing that plan.

10. You have the right to meet with staff to review and update the plan on a regular basis.

11. You have the right to refuse to take part in research without affecting your regular care.

12. You have the right to not receive unnecessary or excessive medication.

13. You have the right to have information about you kept private and to be told about the times when the information can be released without your permission.

14. You have the right to be told in advance of all estimated charges and any limitations on the length of services of which the facility is aware.

15. You have the right to receive an explanation of your treatment or your rights if you have questions while you are in treatment.

16. You have the right to make a complaint and receive a fair response from the facility within a reasonable amount of time.

17. You have the right to complain directly to the Department of State Health and Human Service at any reasonable time.

18. You have the right to get a copy of these rights before you are admitted, including the address and phone number of the Department of State Health and Human Service.

19. You have the right to have your rights explained to you in simple terms, in a way you can understand, within 24 hours of being admitted.
Today's Date *

Month Day Year
Date
Signature *

Clear

Client Bill of Rights and Responsibilities Cont.
Client Number: *
Provided by Counselor
Name: (Last Name, First Name)
Include comma after last name.
Client Responsibilities:
1. Keep counseling appointments as scheduled or call to cancel 24 hours in advance.
2. Refuse to engage in illegal activities, violent or aggressive behavior toward other clients, visitors or staff and avoid the use of illegal drugs or alcohol prior to attending treatment sessions.
3. Participate in random drug tests.
4. Identify a Support Program and begin regular attendance.
5. Seek the support of family/significant other to be involved with your treatment.
6. Reassess your peer group and limit contact with those who continue to use.
7. Refrain from bringing firearms or any kind of weapons onto STAR Council on Substance Abuse property.
8. Be responsible for your fee and make payment arrangements with STAR Council on Substance Abuse.
9. Discuss with your counselor or his/her supervisor any complaints with your experience at STAR Council on Substance Abuse.
10. Make a commitment to follow-up with counseling assignments.
11. Respect the confidentiality of other clients of STAR Council on Substance Abuse.
12. Recognize that you are the only one who makes the changes needed to improve your emotional well being.
Staff Responsibilities:
1. Inform the client of professional qualifications, credentials, and specialized training completed.
2. Involve the client in the treatment process by discussing the service plan and obtaining the client's signature.
3. Begin and end sessions within the time frame scheduled.
4. Timely response to requests for client records or consultation with others as requested or approved by the client's written consen t.
5. Communicate with your insurance company to complete the process of certifying your sessions as required rd for reimbursement from 3 party insurance.
I have read and understand my rights and responsibilities as a client. I have received a copy of these rights.
Today's Date *

Month Day Year
Date
Signature *

Clear

Non-Discrimination Policy and Complaint Procedure
Client Number: *
Provided by Counselor
Name: (Last Name, First Name)
Include comma after last name.
Non-Discrimination Policy Statement:

STAR Council is in compliance with Title VI of the Civil Rights Act of 1964 (Public Law 88-352), the Age Discrimination Act of 1975 (Public Law 94-135), the Rehabilitation Act of 1973 (Public Law 93-122), and the Americans with Disabilities Act of 1990 (Public Law 101-33 This is an equal opportunity program. No person, in the United States shall, on the grounds of race, color, national origin, age, sex, disability, political belief or religion, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination.
Procedure for Filing a Discrimination Complaint:

Any person alleging discrimination based on race, color, national origin, age, sex, disability, political beliefs, or religion has the right to file a complaint of the alleged discriminatory action with the Executive Director of STAR Council and/or you may contact:
Civil Rights Office (MC W206)

Texas Health and Human Services Commission

701 W. 51st Street

Austin, Texas 78751

Phone: (888) 388-6332 or (512) 438-4313

Email: HHSCivilRightsOffice@hhsc.state.tx.us.

STAR Council will explain the complaint system to each individual who expresses an interest in filing a discrimination complaint and shall advise the individual of the right to file a complaint in all available systems.

All complaints must be files no later than 180 days from the date of the alleged discriminatory action. Under special circumstances the Civil Rights Department may extend this time limit. Complaints will be acknowledged and documented within 24 hours (72 hours on weekends The client will be informed of the findings and recommendations within seven (7) calendar days. Final disposition of all claims will take place within 30 calendar days.
General Complaint Procedure:

Complaints regarding this service may be directed to the Director of Treatment Services or the Executive Director. Any staff will assist you at any time in preparing your written complaint or contacting the person you need to talk with about your concern.

If your concern or complaint is not satisfactorily resolved, you may contact:
Substance Abuse Facility Investigations (MC 1979)

Texas Health and Human Services Commission

P.O. Box 149347

Austin, Texas 78714-9347

Hotline: (800) 832-9623
Consumer Services and Rights Protection/Ombudsman Office (MC 2019)

Department State Human Services

P.O. Box 149347

Austin, TX 78714-9347

(512) 206-5760 or Toll Free: (800) 252-8154

I acknowledge I have been provided information regarding non-discrimination policy as well as information on how to file a complaint against STAR Council. I have been provided a copy of the policies and an opportunity to ask questions.
Today's Date: *

Month Day Year
Date
Signature *

Clear

Acknowledgment of Confidentiality
Client Number: *
Provided by Counselor
Name: (Last Name, First Name)
Include comma after last name.
I understand that my records are protected under Federal and State Confidentiality regulations (290-DD-3; 42-USC-290-EE-33; 42 CFR, Part 2) and cannot be disclosed without my written consent.

Exceptions to the above area are as follows: 1. The disclosure is allowed by a court order based upon findings of good cause; or 2. The disclosure is to medical personnel for medical emergency, to qualified personnel to conduct scientific research, management audits, financial audits, or program evaluation.

STAR Council may not say that an individual is present if to do so would reveal that the individual is a client of the facility, unless that individual consents in writing to have his/her presence acknowledged or unless an authorizing court order is presented permitting that acknowledgment.

In three cases, a counselor is required by Texas Law to contact the appropriate authorities if made aware of the following situations or serious intentions to commit a harmful action.

These three cases are:
1. ChildElder Abuse-sexual, physical, or neglect.
2. Suicide-harm against self
3. Violence against another person-intended victim will be notified if at all possible.
According to regulations, STAR Council may, but is not required, to allow an individual to inspect his/her record. It is a criminal penalty for violation of Federal Law or regulations disclosing confidentiality of alcohol and drug abuse individual records; a fine of not more than $500.00 for the first offense, and not more than $1000.00 for each subsequent offense may be assessed.

Suspected violations may be reported either to STAR Council’s Executive Director, the National Institute on Alcohol Abuse and Alcoholism, 6000 Executive Blvd #402, Rockville, MD 20852, or to the United States Attorney for the Judicial District in which the violation occurs.
Today's Date *

Month Day Year
Date
Signature *

Clear

Re-admission Program Rules
Client Number: *
Provided by Counselor
Name: (Last Name, First Name)
Include comma after last name.
Clients who are discharged for non-compliance, defined below, must complete the following list of requirements before they are eligible for re-admission into STAR Council's Outpatient Treatment Program.

The following behaviors could possibly result in a non-compliance discharge from the program.
- Missing group and/or individual sessions within the first 3 weeks. (excluding medical situation)
- No more than two missed within the first 6 weeks.
- No call no shows – Individual and Group sessions
- Excessive late arrivals to appointments and group.
- Lack of communication with Primary Counselor on absence related issues.
- Consumption of Drugs and/or Alcohol during treatment episode.
In the case of an unsuccessful discharge from the program, the client must comply with the following criteria for re-admission into the program:
- Written 2 page summary of what is motivating him/her to return to treatment.
  - Should include all aspects of their particular situation such as family, work, legal problems, health problems, etc.
- Check-in calls daily with STAR Council’s Receptionist.
  - Calls must be at the same time for two consecutive weeks; Monday, Tuesday, Wednesday, and Thursday.
    
    Receptionist will be advised of your call time by Primary Counselor.
  - Check-in calls will be recorded in CMBHS by the Receptionist and Primary Counselor will be notified.
- Attend a minimum of a ten AA, NA, or another community based recovery meeting and provide documentation of attendance to the primary counselor upon return to the program.
If the above requirements are not met and he/she is still requesting re-admission:
- A triage meeting between STAR Council’s Director of Treatment Services, Client’s Primary Counselor, Client seeking readmission and client’s referral source (PO, CPS, etc.).
  - Meeting will determine the individual’s barriers to engaging in treatment.
  - It is also important to include individual’s referral source to support the client and counselor in obtaining a commitment of motivation for treatment from the individual.
Date *

Month Day Year
Date
Signature *

Clear

Dress Code Policy
Client Number: *
Provided by Counselor
Name: (Last Name, First Name)
Include comma after last name.
1. No short skirts or shorts above the mid-thigh.

2. No alcohol or drug related advertisements, profanity, or sexually explicit material on clothing.

3. No midriff showing.

4. Shoes must be worn at all times.

5. No sagging pants.

6. No see-through blouses.

7. No halter tops.

Noncompliance with the dress code may result in being asked to go home to change or being asked to leave group, without receiving credit.

I certify that I understand the above information.
Today's Date: *

Month Day Year
Date
Signature *

Clear

Client Handbook Acknowledgement
Client Number: *
Provided by Counselor
Name: (Last Name, First Name)
Include comma after last name.
By entering my full name below I am attesting that I have received a copy of the following documents in the Client Handbook.
Enter intials to reflect recipt for each of the following documents provided to you in the Client handbook.
Informed Consent for Treatment
Client Bill of Rights and Responsibilities
Non-Discrimination Policy & Complaint Procedure
Acknowledgement of Confidentiality
Re-Admission Program Rules
Dress Code Policy
Client Co-Payment Agreement
HIPAA Notice of Privacy Practices
The above documents have been explained to me in totality, and I was given a chance to ask questions about each document prior to signing.
Today's Date: *

Month Day Year
Date
Signature *

Clear

Client Attestation

This form is optional based on Counselor Instruction
Client Number: *
Provided by Counselor
Date:

Month Day Year
Date
Name:
Include comma after last name.
1. I am signing this letter to declare that I currently do not have any income from any source. My financial support comes from (please describe)
Tell us who pays your bills, how much they give you a month, or if you are about to start a job what will the hourly rate be.
2. I am not receiving unemployment or disability payments.

3. I agree to notify STAR Council about changes in my income within 14 days of the change.

I certify that this information is true and accurate.
Today's Date

Month Day Year
Date
Signature

Clear

Co-Payment Agreement
Client Number: *
Provided by Counselor
Name: (last Name, First Name)
Include comma after last name.
- Co-payments, if you have any, are due at each appointment unless other arrangements have been made and approved by the Director of Treatment Services.
- STAR Council does not extend personal credit. Payment may be made by credit card by contacting the main office at (800) 375-1395.
- Further appointments may not be made until the balance is paid unless other arrangement have been made and approved by the Director of Treatment Services.
- Any change of employment status, family income or insurance coverage must be made available to STAR Council at the next scheduled session. Fees will be adjusted as employment or income status changes.
I am responsible for the following payment per Individual Session:
I am responsible for the following payment per Education Group Session:
I am responsible for the following payment per Process Group Session.
By entering my full name below I attest that I have read, or have had read to me, the above co-pay agreement and agree to abide by it. I also agree to inform my counselor of any changes in my financial status while in treatment.
STAR Council Treatment clients will be required to attend all groups and individual sessions as required by their level of care and assigned by their Primary Counselor.

Any missed sessions must be excused by calling the counselor 24 hours prior to the scheduled appointment. Excessive absences may result in your discharge from the program. If you are discharged from the program for excessive absences you must complete a re-admission criteria/plan with your counselor before being re-admitted.
Today's Date: *

Month Day Year
Date
Signature *

Clear
Should be Empty:

Informed Consent for Treatment

Client Bill of Rights and Responsibilities

Client Bill of Rights and Responsibilities Cont.

Client Responsibilities:

Staff Responsibilities:

Non-Discrimination Policy and Complaint Procedure

Acknowledgment of Confidentiality

Re-admission Program Rules

Dress Code Policy

Client Handbook Acknowledgement

Client Attestation

Co-Payment Agreement