CLIENT INFORMATION

OTHER PAYORS AND/OR RESPONSIBLE PARTY – If the client under the age of 18, the accompanying parent/guardian will be listed as the guarantor.

When you make an appointment at River City, that time is reserved for your multidimensional assessment, treatment planning and any recommended treatment. These treatment appointments may last between 45-90 minutes. Regular attendance is an essential part of successful and effective treatment. The following attendance policy reflects the needs of the client as well as the needs of our treatment professionals.

ATTENDENCE: You are expected to attend all scheduled treatment (individual, group and family) sessions. Only three (3) unexcused absences will be allowed during the course of your treatment program. In the event of a fourth unexcused absence, you will have to meet with treatment staff and/or our office manager to continue to be enrolled in treatment. In the case of court-involved individuals, your case manager will be notified and recommended action will be implemented. Any missed groups must be made up prior to discharge from the program.

 

ARRIVE EARLY and LATE ARRIVALS: You are expected to arrive 5-10 minutes early for individual and family therapy sessions to take care of any administrative issues that may come up and to relax before your session. If you anticipate arriving late for your individual session, please call us so that we can notify your therapist. For those attending River City’s groups, you should arrive 15 minutes before the scheduled start of the group in order to sign in and submit to a breath and/or drug screen. This is especially important for those clients participating in our VASAP approved groups and any other court-involved individuals. All groups will start promptly at the indicated time. As groups are only 60 minutes in length, anyone arriving 5 minutes or later after the start of the scheduled group will not receive credit for attending that particular group. You have the option of attending the remaining group session without VASAP credit, or not attending which will result in an unexcused absence.

 

CANCELLATIONS: If you must cancel an appointment, at least 24-hours notice is required. This gives us adequate time to offer that time to another client (we often have a waiting list of clients who need appointments LATE

 

CANCELLATIONS AND NO SHOWS: For all appointments cancelled with less than 24-hour notice and/or when any client does not show for their appointment, a “no-show fee” will be charged on your account for the full rate for the appointment. The no-show fee must be paid before another appointment can be scheduled.

 

CANCELLATION VERFICATION: Occasionally emergencies happen and an absence may be necessary. You must contact our office, by phone or email prior to group. You may be asked to provide verification of your absence. If it is a valid reason with documentation, you may not be charged the “no show” fee.

 

DISCHARGE FROM TREATMENT/MISSED APPOINTMENTS): For VASAP clients, if you miss two (2) appointments consecutively, you will be discharged as of that day. Excessive no-shows or cancellations will also be grounds for discharge for every client and are at the discretion of treatment staff and the office manager. At return to treatment will require the following: (1) payment of no-show fees, and (2) a credit/debit on file for future fees.

 

DOCUMENTATION OF ATTENDENCE: An attendance roster will be provided by treatment staff for you to sign at each group session that confirms your attendance and the psychotherapy progress note will serve as documentation of any individual and family therapy sessions. This will include your final session with River City that includes the Discharge Summary. Anyone found to be forging signatures may be terminated from our treatment program with notification to your case manager, probation officer, and/or emergency contact.

 

RIVER CITY CLOSINGS: We are closed for most major holidays: New Year’s Day, Martin Luther King Day, Presidents’ Day, Memorial Day, Independence Day, Labor Day, Fall (Indigenous People’s/Columbus) Day, Veterans’ Day, Thanksgiving Day and the following Friday, Christmas Eve, and Christmas Day. It is important that you provide us with updated and accurate contact information, so that we can inform you via voicemail and/or text.

 

INCLEMENT WEATHER SCHEDULE: In the event of inclement weather, we follow Richmond Public Schools closings for the Richmond office, and Petersburg Public Schools closings for the Petersburg office. It is important that you provide with us updated and accurate contact information, so that we can inform you via voicemail and/or text.

 

COLLECTION OF TREATMENT FEES: River City strives to assist all clients in meeting their financial obligation prior to enlisting the assistance of a collection agency. Third-party debt collection agencies may be enlisted only after all reasonable collection and payment options have been exhausted. Collection agencies may help resolve accounts for services where patients are uncooperative in making payments, have not made appropriate payments, or have been unwilling to provide reasonable financial and other data to support their request for hardship.

 

FORMS: An appointment is required to have forms filled out by treatment staff.

 

QUESTIONS: Please discuss any questions or concerns that you might have regarding this policy with the office manager.

 

Services may be covered in full or in part by your health insurance or employee benefit plan. If you wish to utilize your insurance coverage, River City will submit claims on your behalf. You will be expected to make your co-payment, deductible, or any amount not covered by your insurance company or referral/funding source at the time of your appointment. Pre-authorization from your insurance company is not a guarantee of coverage, and you will be responsible for payment of any services that were not covered by your insurance company. You are required to notify River City of any change of insurance PRIOR to your next scheduled appointment. If you do not notify our office of new insurance information, you will be required to pay in full for your visit. Please notify us of any change in address or phone number so that we may contact you if needed.

By signing the orientation checklist, you certify:

 

1.You have read and agree to River City Integrative Counseling’s (River City) payment policy.

 

2.You are eligible for the insurance indicated on the client information form and understand that payment is your responsibility regardless of insurance coverage.

 

3.You authorize River City to release any medical information to your insurance company or third party payor necessary to facilitate processing insurance claims on your behalf.

 

4.You understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency. All appointments that are cancelled without a 24- hour business day notice a “no-show fee” will be charged on your account for the full rate for the appointment. The no-show fee must be paid before another appointment can be scheduled A $35.00 returned check fee will be charged for checks returned due to insufficient funds.

 

5.You choose to receive communications from River City by text or voice at the phone number you provided, including but not limited to communications about appointments, treatment, and payment. You understand that communication may not be secure and there is a risk that they may be read or heard by a third party.

As a practice, we feel strongly about the importance of healthy boundaries and respecting your time and our time. As such, it is our decision to prevent balances from accruing in order to preserve the integrity of the therapeutic relationship. We require a credit card to be kept on file at all times in the event of an unforeseen balance. A credit card authorization form will be completed at the time of your intake appointment and your therapist will review this policy with you in person should you have any questions.

As a client, parent, and/or legal guardian/authorized representative on behalf of your child under age 18, you hereby assume all risk of and release, forever discharge, and agree to hold harmless River City, and its owners, directors, employees, contractors, students, interns, affiliates, and volunteers from any and all liability, claims, or demands for personal injury, illness, death, damage, and expense as a result of participation in any River City Integrative Counseling (River City) and/or its affiliate organizations, programs, and services. This release of liability includes, but is not limited to programs, services and activities such as: individual, group and family counseling and therapy, home visits, school visits, diverse community outings, case management, discharge from services against medical advice, transportation to and from activities, on the property of River City, use of the behavior management system, bodily search, administration of medication, alcohol and/or drug screens, engaging with staff, volunteers, or agents of River City or other activities related to treatment programs and services.

You also further authorize River City to provide therapeutic, psychosocial, and medical services and care to yourself and/or your child and to obtain medical care from any licensed physician or hospital should you and/or your child become injured. You assume the responsibility of any emergency medical expenses and/or bills, if any.

Without limiting the scope of release, waiver, and your assumption of risk, you understand this document will prohibit you from bringing a lawsuit or otherwise claiming damages against River City or any of its affiliates. By signing the orientation checklist, you indicate that you have read and understand this release of liability and agree to all the contents contained therein.

 

NAME OF PERSON AND/OR PROGRAM RECEIVING AND/OR RELEASING INFORMATION:

RIVER CITY INTEGRATIVE COUNSELING 

5511 STAPLES MILL ROAD, SUITE 300

RICHMOND, VA 23228

PHONE NUMBER: 804.681.2525

FAX NUMBER: 804.230.0998

THE EXECUTION OF THIS FORM DOES NOT AUTHORIZE THE RELEASE OF INFORMATION OTHER THAN THAT SPECIFICALLY DESCRIBED ABOVE. THE INFORMATION REQUESTED ON THIS FORM IS SOLICITED UNDER TITLE 38, U.S.C. THE FORM AUTHORIZES RELEASE OF INFORMATION IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 42 CFR PART 2, 45 CFR PARTS 160 AND 164, 5 U.S.C. 552A, AND 38 U.S.C. 5701 AND 7332 THAT YOU SPECIFY. RECIPIENTS OF THIS INFORMATION ARE FORBIDDEN FROM RE-DISCLOSURE WITHOUT THE SPECIFIC FURTHER INFORMATION AUTHORIZATION AS CITED BY THE CODE OF FEDERAL REGULATIONS SECTION 2.31 OF PI.L 93-282 42 PART 2. I UNDERSTAND THAT THIS AUTHORIZATION MAY BE WITHDRAWN AT ANY TIME IN WRITING, EXCEPT TO THE EXTENT THAT THE AGENCY OR THE PERSON WHO IS TO MAKE THE DISCLOSURE HAS ALREADY ACTED IN RELIANCE ON IT. THIS AUTHORIZATION WILL REMAIN IN EFFECT THROUGHOUT THE COURSE OF TREATMENT AND FOR A MAXIMUM OF 90 DAYS FROM DISCHARGE UNLESS OTHERWISE WITHDRAWN. I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY AND THAT I MAY REFUSE TO SIGN THIS FORM. MY REFUSAL TO SIGN WILL NOT AFFECT MY ABILITY TO OBTAIN TREATMENT.

River City Integrative Counseling’s Alcohol and Drug Treatment Program is designed to assist you in obtaining the knowledge and skills necessary to reduce and/or eliminate your substance use (alcohol and drugs), identify and manage the triggers that lead to substance use, and manage relapse events with the utmost confidentiality and professionalism. Our goal is to reduce the impact of substance abuse and co-occurring mental health disorders for individuals, families, and communities in Virginia.

For those individuals involved with the criminal justice system due to a DUI or other criminal activity, we want to support you in complying with the requirements of the courts. We work in collaboration with your VASAP case manager, attorney, probation and parole, and the courts to coordinate a treatment protocol that includes regular alcohol and drug testing and reporting, to give the courts confidence that you will not recidivate.

Regardless of why you are seeking alcohol and drug treatment, River City believes that it is important to inform all clients of our treatment expectations and recommendations, as it helps you prepare for such an important commitment to your life. Your treatment recommendation is: group therapy sessions and individual/family therapy sessions. Total number of treatment sessions to be completed is:

Our team is made up of substance abuse professionals that are here to guide you during your treatment. While participating in River City’s programs I agree to:

MULTIDIMENSIONAL ASSESSMENT: Your course of treatment is determined by a multidimensional assessment that includes substance abuse screening tools such as the SASSI, AUDIT, CAGE and others. I agree to participate fully in the assessment and give honest answers to my assessor. ASAM CERTIFIED

ASSESSORS: Your assessor will determine the best course of treatment. I agree to comply with the assessor’s recommendations and attend all group sessions.

COMPLIANCE AND REPORTING: River City works closely with your case manager and/or probation officer, and attorney, if you have one. Your progress and any non-compliance are reported to him or her.

PARTICIPATION AND COMMITMENTMENT: In order to achieve positive results, you must attend and actively participate in the prescribed treatment, whether individual, group and family therapy or some combination of them all. If you are not attending and actively participating, the treatment staff will note this in your file, and it will be reported to your case manager.

ALCOHOL AND DRUG FREE: I agree to remain drug and alcohol free during my course of treatment at River City.

ATTENDANCE: You are expected to attend all scheduled group sessions. Only three (3) unexcused absences will be allowed during the course of your treatment program. In the event of a fourth unexcused absence, you will have to meet with treatment staff and/or office manager to continue to be enrolled in treatment. In the case of court-involved individuals, your case manager will be notified and recommended action will be implemented. Any missed groups must be made up prior to discharge from the program.

VERIFICATION: Occasionally emergencies happen and an absence may be necessary. You must contact our office, by phone or email prior to group. You may be asked to provide verification of your absence.

ARRIVE EARLY: You are expected to arrive 15 minutes before the scheduled start of the group in order to sign in and submit to a breath and/or drug screen. All groups will start promptly at the indicated time. Anyone arriving five (5) minutes or later after the start of the scheduled group will not receive credit for attending that particular group. You have the option of attending the remaining group session without credit, or not attending which will result in an unexcused absence.

DOCUMENTATION OF ATTENDANCE: An attendance roster will be provided by treatment staff for you to sign at each group session that confirms your attendance and the psychotherapy progress note will serve as documentation of any individual and family therapy sessions. This will include your final session with River City that includes the discharge summary. Anyone found to be forging signatures may be terminated from our treatment program with notification to your case manager, probation officer, and/or emergency contact.

12-STEP EFFECTIVENESS: 12 step programs (NA, AA) have been shown to be effective in assisting clients manage their alcohol and drug use. During your treatment at River City, we encourage you to attend these meetings.

12-STEP MEETING LIST: River City will provide you with a list of NA/AA programs in the metro Richmond/Petersburg area. These programs are free of charge and the selection of group to attend and location is at your discretion.

SCHEDULE OF FEES: You will be provided with a schedule of treatment fees. We reserve the right to modify or change these fees at any time.

10% DISCOUNT: We offer a 10% discount for paying in advance. If you wish to pay your treatment fees in advance, we will be happy to calculate this for you.

PAYMENT METHODS: River City Integrative Counseling accepts cash, credit card, money orders, or personal checks. Note: Cash must be exact amount (any excess will be a credit to your account at the time of service), returned checks will have a $35.00 fee attached, and an authorization form must be completed for any credit card used or stored on file.

PAYMENT AND ATTENDANCE: All clients are expected to pay their individual and/or group therapy fees prior to attending each treatment session. Individual and/or group therapy fees may be paid in advance. If your account incurs an unpaid balance, you will not be allowed to participate in the program, and this will be noted in your file, as well as reported to your case manager and/or probation officer.

FINAL PAYMENTS AND PROGRAM COMPLETION: All treatment fees must be paid before you will be marked as having successfully completed the program. There are NO exceptions to this rule. Court-involved individuals are usually not released from VASAP, probation and parole, etc., until River City confirms your total treatment completion, which includes full payment of services.

PAYMENT QUESTIONS: If there are questions about treatment fees or concerns regarding your ability to pay, please feel free to direct them to the Office Manager, Madison Cully, at (804) 681-2525.

For VASAP and/or court-involved individuals, in order for you to be confirmed as successfully completing treatment, the following requirements must be met:

1.You must have a $0 balance on your account.

2.You must attend ALL classes in a timely manner, and actively participate during the course of your treatment.

3.You will be required to attend a one-on-one, 60-90 minute discharge session with one of the treatment staff.

4.You must submit to ALL breath analysis and random drug screens as outlined in the Alcohol and Substance Abuse policy.

River City believes in the benefit of continuing care to maintain abstinence and strengthen an individual’s commitment for long-term recovery. Any treatment participant that has completed all of their treatment requirements may return to our treatment groups for the reduced rate of $15 per group. Please consult with the Office Manager, Madison Cully, at (804) 681-2525.

The purpose of the River City Integrative Counseling’s Alcohol and Drug Treatment Program is to treat substance abuse and addiction. While our program supports the harm reduction model, we also emphasize abstinence as part of our program. Please note: it is a requirement of VASAP and other legal and criminal justice institutes that you abstain from alcohol and drugs throughout the duration of treatment. As such, use of alcohol and drugs are NOT allowed unless prescribed by a physician and approved by VASAP or the Courts. Please bring your prescriptions to your first scheduled group and we will record them in your file. For River City to support you in your treatment goals and ensure this policy is maintained, breath alcohol analysis will be administered prior to every group and each client will submit to a random monthly drug screen. Any positive results from either the blood alcohol breath analysis or the drug screens will be reported to your case manager and/or probation officer and may result in intensified treatment or expulsion from the program. Additionally, this will be recorded in your file.

Inability to provide a sample will be considered a refusal to provide a sample. Routine and regular urine drug screens are a required component of your treatment. If we are unable to collect samples and complete drug screen tests we will not be able to accurately verify abstinence. Clients who refuse to submit to a urine drug screen and/or breathe analysis will have treatment recommendations increased and VASAP and court-involved individual’s case managers and/or probation officers will be notified. Be prepared to submit a breath analysis and/or urine drug screens every time you come to treatment. This means that if at all possible WAIT UNTIL YOU CHECK IN TO USE THE BATHROOM as you may be asked for a urine sample. All clients will be expected to produce a sample within 1 hour of request. Once a sample has been requested you may not leave our office until drug screen is completed. Failure to submit sample within 1 hour window will be considered a refusal with the above detailed outcome of increased treatment and communication with VASAP, case managers and probation officers.

If at any point in treatment your breath analysis registers as .08 or higher, you will not be allowed to drive. Anyone displaying signs of impairment will have to surrender their keys to treatment staff and will have to either take another mode of transportation home or have some responsible party pick them up from our office. You will not be permitted to take the bus. Court-involved individuals will have this noted in their file and reported to your VASAP case manager and/or court directed case manager.

NOTE: Any attempt to leave River City offices while impaired will result in River City staff first calling 911 to inform them of your danger to the public, then to your VASAP or court directed case manager and/or your probation officer.

BREATH ANALYSIS BETWEEN .01 - .079: You will be permitted to participate in group provided you show no visible signs of intoxication. This will be left to the discretion of the treatment staff.

BREATH ANALYSIS OF .08 OR ABOVE: You will not be allowed to participate in group and this will also count as a group session absence.

If your random drug screen is positive for any illegal substances, you will be asked to sign a document as verification of the positive drug screen. If you want to contest the results of the drug screen, the sample may be sent to the lab for independent verification, at your cost, which must be paid within two (2) business days. If the contested drug screen returns positive, it will result in intensified treatment or suspension from the program pending a treatment team meeting with VASAP, treatment staff and/or the office manager. You may still participate in the individual and/or group session as long as you are not exhibiting any serious visible signs of impairment or distraction to other group participants. If at any point during the treatment session the treatment staff feels that you are showing signs of impairment, he/she reserves the right to ask you to leave, and this will be marked as an absence. Anyone displaying signs of impairment will have to surrender their keys to treatment staff and will have to either take another mode of transportation home or have some responsible party pick them up from our office. You will not be permitted to take the bus. Court-involved individuals will have this noted in their file and reported to your VASAP or court directed case manager.

NOTE: Any attempt to leave River City offices while impaired will result in River City staff first calling 911 to inform them of your danger to the public, then to your VASAP or court directed case manager and/or probation officer.

Treatment participants who adulterate, dilute, or otherwise tamper with a drug screen will be temporarily suspended until they meet with treatment staff and the office manager. Court-involved individuals will be reported to their VASAP or court-directed case manager and/or probation officer. This may result in a criminal sanction.

ASAM Multidimensional Assessment - $150 Per Assessment

 

Therapy Intake Session - $125 Per Assessment

 

Individual Therapy - $100 Per 45 - 60 Minute Session

 

Family or Couples' Therapy - $125 Per 45 - 60 Minute Session

 

Group Therapy - $50 Per Group Session

 

Breath Analysis - No Cost

 

Drug Screen - $20 Per Drug Screen

 

Court or Legal Letters - $25 Per Letter

 

Court or Legal Telephone Calls - $25 Per Call

 

Court or Legal Appearance and Case Management - $50 Per Hour

 

Treatment Staff Mileage for Offsite Consultation - $0.54 Per Mile

 

NSF Returned Checks - $35.00 Per Occurrence

 

Late Cancellation/Missed Appointment Fee - Full-Rate of Appointment Per Occurrence.

 

 

ASAM Multidimensional Assessment - $70.00 per assessment

 

Breath Analysis - No cost

 

Drug Screen - $20.00 per screen

 

Group Counseling Sessions - $30.00 per group

 

Individual Counseling (45 - 60 minutes) - $70.00 per session

 

Court or Legal Letters - $25.00 per letter

 

NSF Returned Checks - $35.00 per occurrence

 

Cancellation/Missed Appointment - $35.00 per occurrence

 

Discharge Session/Summary - $70.00 per occurrence

 

Case Review - $35 per occurrence

 

*Please contact the office manager for additional fees and services.

PRINT AND COMPLETE THIS AUTHORIZATION AND RETURN.

 

All information will remain confidential.

I authorize River City Integrative Counseling to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.

Program and Client Handbook

Introduction

River City History

            River City Comprehensive Counseling Services, Inc. (River City) was established in 2009 and has been committed to providing quality psychiatric and substance abuse services for individuals aged 5 through older adulthood who experience emotional, mental, and behavioral conditions that negatively impact their lives. Our therapeutic programs and structure are designed to promote recovery by improving psychiatric symptoms, preventing and assistance accessing vital community resources necessary for successful functioning in professional provides superior psychiatric and addiction services while respecting participant dignity and rights.

River City Mission and Vision – 12 VAC 35-105-570 Mission statement.

            River City is committed to providing comprehensive psychiatric, mental health and substance abuse treatment programs and services that are client-driven, family-focused, and research-based. Our mission is to provide a full range of clinical treatment and support services to manage emotional, mental, and behavioral conditions, as well as substance abuse disorders.

Services provided by River City- 12 VAC 35-105-580. Service description requirements.

            At River City, we set a high standard of care by offering comprehensive community and facility-based programming such as:

Community-based services:

            Intensive in-home services (IIHS): Intensive home and community based treatment (3-10 hours weekly) for individuals ages 5-16 that focuses on preserving the family system by providing interventions designed to prevent out-of-home placements such as hospitalizations, group home placements, and incarceration. The goal of these services is to stabilize the client and family system through intensive skill-building to bring about positive community functioning.

            Mental Health Support Services (MHSS): Intensive home and community-based treatment (3-10 hours weekly) for individuals 16-older that focuses on assisting individuals to maintain community stability and independence through independent living skills, resource management, and monitoring of psychiatric and medical care. The goal of service is to prevent hospitalizations, homelessness, and incarceration by enhancing the individual’s coping and adapting skills.

Facility-based services:

Mental Health Clinic: Our mental health clinic specializes in providing outpatient psychiatric and substance abuse services. We provide top quality psychiatric and substance abuse services dedicated to helping children, adults, and their families restore and maintain emotional and physical health and wellness outside of a hospital setting. River City’s Mental Health Clinic offers individual and family therapy, crisis intervention, and a diverse blend of group offerings such as: cognitive and dialectical behavioral therapy (DBT) skills groups, MET groups, relapse prevention, anger management, DUI groups, and more.

Philosophy of Service

            River City takes pride in providing psychiatric, substance abuse care, residential living, and community based services that is second to none. Our team of physicians, licensed clinical social workers and professional counselors, licensed-eligible, certified substance abuse counselors, and other qualified mental health professionals are available for your needs.

Structured Program of Care:

            River City’s Structured Program of Care is, “A comprehensive and planned daily, weekly, monthly routine including appropriate supervision that meets the needs of the client and their family,” that includes, but is not limited to:

·                     Bio-psychosocial assessment

·                     Psychiatric evaluation

·                     Medication evaluation

·                     Individualized or Person-Centered Service Plan (ISP or PCP)

·                     Intensive crisis stabilization and treatment (IIH and MHSS)

·                     Crisis intervention

·                     Substance abuse treatment

·                     Individual, Group, and Family Therapy

·                     Independent case management

·                     Community resourcing

·                     Recreation and leisure activities

·                     Continuing care

 

Family Education and Counseling:

            We believe that family members can be the corner-stone of successful outcomes for our clients. River City actively engages and partners with family members in the treatment process to provide the best support possible for clients. The goal of engaging the family is to help them improve communication, solve family problems, and understand and handle special situations that they may develop their own methods of managing family problems more effectively.

Mental Health Statement:

            All clients will be evaluated by a licensed mental health professional. The licensed mental health professional may or may not evaluate and concur or not concur with a preexisting diagnosis. The licensed mental health professional may also provide a new or different psychiatric diagnosis along with medication. You have the right to a second opinion regarding any diagnosis that you may obtain while in services with River City.

 

Client Information

Client Bill of Rights and Responsibilities – 12 VAC 35-105-570. Compliance with applicable laws, regulations and policies.

            Every client receiving services from River City Integrative Counseling Services, Inc. has inherent rights and responsibilities. These Client Rights and Responsibilities are discussed during the assessment and admission process, distributed to clients via the Client Handbook and are posted in all of our facilities. Additionally, our professionals receive annual training on various topics related to providing and protecting client’s rights and responsibilities. Prior to the beginning of treatment services, you will read and are asked to sign the Client Orientation Checklist, which acknowledges your voluntary participation in River City programs and services and your understanding of these client rights and responsibilities and other important aspects of your health care.

Client Rights As a client you have the following rights:

Professional Standards                                                                                                         

·         The right to quality care delivered by professionals who have met all pertinent requirements.

·         The right to quality healthcare that is professional and courteous, which does not discriminate because of age, race, disability, national origin, religious beliefs, gender, sexual orientation, political affiliations or veteran status. You have a right to healthcare that is free from harassment of any kind.

·         The right to safe care that is delivered in a facility that complies with safety standards. You have a right to know what measures are taken to assure your safety such as emergency preparedness drills, fire drills and inspections.

 

Treatment Participation

·         The right to participate in the development and review of your treatment plan, including known effects of receiving or not receiving such treatment and alternative treatment as may be available.

·         The right to receive care that is medically needed

·         The right to refuse treatment against medical advice to the extent permitted by law. If you refuse the recommended treatment and/or leave any program or service against advice, neither River City, any employee of River City, nor our related physicians will be held responsible for any to you or others as a result of this action.

·         The right to choose another provider at any time.

Least Restrictive Setting

·         The right to receive treatment in the least restrictive setting that responds to your treatment needs.

·         The right to have Freedom From Seclusion and Restraints used for the Management of Behavior unless clinically required.

Confidentiality – 12 VAC 35-105-570. Confidentiality of records. 12 VAC 35-105-870. Written records management policy.

·         The right to confidential maintenance of information about yourself and treatment received. We may not tell a person outside this agency that you attend our programs or discuss any information identifying you as a client within our services without written authorization or as allowed by law (including court orders, medical emergency, program evaluation by Center staff, suspected abuse or neglect, to report a crime or a threat to harm someone, etc.).

·         The right to have your records kept in a locked steel file in a locked room.

Access to Information and Records

·         The right to inspect your own record in the presence of your primary therapist and, under most conditions, the right to have a copy of your own record at your expense.

·         The right to access information in sufficient time to facilitate your decision-making.

·         The right to ask your healthcare provider for current information in understandable terms regarding your diagnosis, treatment, and anticipated outcome.

Constitutional/Civil Rights

·         The right to exercise constitutional, statutory, and civil rights, except those denied or limited by court action. No person shall, on the grounds of race, religion, ethnicity, color, national origin, ancestry, age, handicapped, or sexual preference, be excluded from participation in, be denied the benefit of, or be otherwise subjected to discrimination under any program or activity of the River City in the provision of its services.

Protection From Abuse, Neglect, or Exploitation

·         The right to humane care and protection from harm. Staff are prohibited from any use of psychological abuse, including humiliating, threatening, and exploiting actions. All instances of abuse, neglect or exploitation should be reported to River City staff immediately.

Waivers

·         The right to waive your rights. At no time will admission to services be conditional upon a person’s waiver of their rights. However, you retain the option to waive any of your rights. Such a waiver must be given voluntarily, knowingly, and in writing and can be withdrawn at any time.

Informed Consent

·         The right to have informed consent, refusal, or expression of choice regarding: 1) the delivery of services; 2) release of confidential information; 3) any concurrent services; or 4) the composition of your treatment team.

·         The right to have your guardian, next to kin, or legally authorized responsible person be granted the right to exercise, to the extent permitted by law, your rights if you have been declared incompetent in accordance with the law; are found by your health care provider to be medically incapable of understanding the proposed treatment or procedure; are unable to communicate your wishes regarding treatment; or are a minor.

Legal Counsel

·         The right to contact or consult with legal counsel of your choice at your own expense.

Consumer Advocate; Questions, Concerns, or Grievances

·         The right to have your questions answered or to make complaints about services you receive or violations of these rights…and to have those complaints heard and decided promptly.

·         If you have a grievance or complaint, River City staff will contact you within 3 days to discuss the complaint and update you as to the status of the investigation. Any complaint should be taken to: (1) your case manager, or (2) the River City Human Rights Advocate.

Financial: Explanation of Treatment Fees and your Bill

·         The right to information regarding fees for services and programs. This includes being notified of what services may be involved, additional charges, the nature of the charges and methods of payment.

·         The right to information about your bill. (The Medicaid program does not allow providers to furnish a copy of the bill to the client.)

·         The right to inquire about financial assistance in paying your bill.

Client Responsibilities: As a client, you are responsible for the following:

·         Provide accurate and complete information about your past illnesses, hospitalizations, medications and other matters relating to your health, and to answer any questions concerning these matters.

·         Inform staff immediately if you are experiencing homicidal or suicidal ideations.

·         Ask questions if you do not understand the explanation of your diagnosis, treatment, prognosis or any instructions.

·         Cooperate with health care staff by following instructions concerning medications, follow-up visits, education recommendations, other essential steps in your treatment plan and to notify your health care provider if this plan cannot be followed or if problems develop.

·         Inform your pharmacist when having prescriptions filled about prescription and over-the-counter medications you are currently taking.

·         Inform River City or any of its professionals of the existence of any advance directive (including health care proxy, power of attorney, DNR, living will) you may have created.

·         The responsibility for prompt payment of your River City bills, to provide information necessary for insurance processing, and to be prompt about asking questions you may have concerning your bill.

·         Conduct yourself in an appropriate manner. Rule violations may lead to a limitation or termination of service. In some cases the police may be called. Visitors and staff shall not: 1) carry or be under influence of intoxicating beverages or illegal substance; 2) steal, attempt to steal, or deface property of River City; 3) assault or sexually harass anyone; 4) possess firearms or dangerous weapons; 5) threaten, intimidate, coerce, or interfere with other people; 6) falsify information provided to River City; 7) smoke inside any River City facilities. Services may also be limited or terminated if a client fails to keep their scheduled appointments.

 

Freedom of Choice

Freedom of Choice and Title VI of the Civil Rights Act of 1964 Statements

            You may choose your mental health care provider in Virginia. You have the right to change mental health care provider at any time. You can also ask for a change for any reason. If you think you have a good reason, you can ask for additional changes. The change may or may not be granted depending on the circumstances.

            River City complies with the Title VI of the Civil Rights Act of 1964, as amended (42 U.S.C. 2000d through 2000d-4a), which requires that no person be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance on the grounds of race, color, or national origin; as well as the Rehabilitation Act of 1973, as amended (29 U.S.C 794), which states that no otherwise qualified client with a disability shall, solely by reason of her or his disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. The Act requires reasonable accommodations for certain persons with disabilities.

            River City agrees to hold information regarding recipients confidential. A provider shall disclose information in his/her possession only when the information is used in conjunction with a claim for health benefits or the data necessary for the functioning of the state agency.

            After carefully reading and having River City explain this document, I attest that I have not been coerced, bribed, offered money nor have I nor my child been offered favors for requesting services with River City Integrative Counseling Services, LLC. I choose to participate in services offered by River City Integrative Counseling Services, LLC.

Advanced Directive

            A mental health advance directive is a written document that describes what you want to happen if you become so incapacitated by mental illness that your judgment is impaired and/or you are unable to communicate effectively. It can inform others about what treatment you want or do not want, and it can identify a person to whom you have given the authority to make decisions on your behalf.

            The law requires mental health providers to respect your mental health advance directive, but they are not required to follow it in all cases. If instructions or preferences in your mental health advance directive are against hospital policy, are unavailable, or would violate state or federal law or immediately endanger you or others, providers are not obligated to comply with those provisions. Also, if you are involuntarily hospitalized under the Involuntary Treatment Act, or are incarcerated in jail, your mental health advance directive may not be fully honored.

 

Grievance Policy and Human Rights – 12 VAC 35-105-490. Written grievance policy.

                River City has a Human Rights Coordinator that can assist you with the complaint and grievance process. This person also monitors staff and all programs and services to ensure that no client or family is experiencing abuse, neglect and/or exploitation of any type.

            What is a Complaint?

            A complaint is an informal way the state allows you to express your dissatisfaction with River City and/or its affiliates. It is a good idea to try and resolve your complaint with the person directly involved or ask the River City Human Rights Advocate to assist you, before you try other things. Explain your concern. Let the person know what would work better for you. Be clear about what your complaint is. Also, be clear about what an acceptable solution will be. Try to find some ways to reach agreement that will satisfy both you and the other person.

            What is a Grievance?

            There are two types of formal complaints that you may make. One type is an appeal, which is a formal complaint about an action. An action is a denial, suspension, reduction, or termination of certain services. See below for a description of the appeal process. The second type is a grievance, which is a formal complaint about any other issue.

            The purpose of this policy and procedure is to prevent and resolve conflict. River City acknowledges that any client, who has a grievance or is dissatisfied with any matter concerning the programs, services or staff at River City, will have the right to lodge a grievance. River City will consider and attempt to resolve any grievance in a timely manner. Any client or group of client may lodge a grievance with River City which is of direct concern to them in terms of the grievance procedure. Management will consider all grievances in a fair and just manner. No harassment of any client who has lodged a grievance will be tolerated. River City will allow parties to call witnesses to testify.

            River City will question witnesses if necessary. The investigation will not proceed if the aggrieved party is not present. Any client lodging a grievance may be accompanied and represented at any stage of the procedure by a colleague of his/her choice. The grievance procedure may be used by all client of River City.

 

Procedure

 

Step 1: Lodge Complaint

 

A client who has a grievance must first notify his/her assigned case manager, who will attempt to resolve the issue within 24 hours of the issue being raised. The manager will inform Human Resources of the grievance.

If the client is not satisfied with his/her case manager(‘s) decision, then the client will have to raise a formal grievance with the next level of Management within two work days of the supervisor/manager(‘s) decision.  

 

Step 2: Formal Grievance

 

If the client is not satisfied with the case manager’s decision, or if the grievance poses concerns for the client’s case manager, then the client shall complete a formal Grievance Form and submit the form to the Management Team within two work days of the case manager’s decision.

The Management Team will schedule a meeting within three work days after having received the formal Grievance Form. The time period may be extended upon agreement by the parties concerned. The Management Team will review the information. The individual filing the formal grievance may be called to attend a meeting if deemed necessary by the Management Team. In the event that a meeting is deemed necessary, the meeting should be attended by the client, case manager, the immediate supervisor, and will be chaired by the manager. In any meeting conducted by the Management Team, with or without the presence of the client, the manager will ensure that minutes are kept of the meeting, whether written or on a tape recording device, however, any decision made will be recorded on the Formal Grievance Form by the manager.

If no satisfactory resolution or decision is reached within two work days of the meeting, The Management Team will assist the client with the next step. This will be noted on the formal Grievance Form and the client will be advised to take the issue to the Human Rights Advocate. This step should be done within two work days.

 

Step 3: Human Rights Advocate

 

This is the highest level within the Company’s appointing authority.

The Management Team (in Step Two) will advise Human Rights Advocate who will review all documents pertaining to the incident. The Human Rights Advocate will review the documents and provide the client with the company’s decision in writing within two work days. The decision made by the Human Rights Advocate will be final. The Human Rights Advocate will advise the client of their rights if the decision reached is not found to be satisfactory by the client. The Human Rights Advocate will supply further contact information for contacting the State Human Rights Committee if necessary.

 

Notice of Privacy

 

1.      Who We Are

This notice describes the Privacy Practices of River City Integrative Counseling Services, Inc. (River City) and includes all individuals who work in or for our programs and services.

 

2.      Our Privacy Obligations

We are required by law to keep your health information (protected health information- PHI) private in many situations, to inform you of these practices and to follow the practices set forth.

 

3.      Disclosing and Using Your Information With Your Consent

When you begin receiving care from River City, we will ask you (or your legally authorized representative) to sign a consent form that will permit us to provide care for you. We will also ask you to sign a reimbursement form granting us permission to obtain preauthorization for your care and/or to bill for the care provided. This may also include providing us with copies of your medical and personal information which may be use for reimbursement as needed. You may revoke your permission that allows us to use your information after the date of revocation, but you must do so in writing. Please note that revocation may affect our ability to provide you with services.

 

4.      Using Your Information (PHI) With Your Authorization

As described above, we will use your signature on the consent form to release information for treatment, payment, or other health care operations. We may use the PHI for other reasons only when we:

 

a.       Have specific authorization signed by you or your legally authorized representative or;

 

b.      There is an exception as described below in section 5.

 

Please note: You have the right to withdraw (revoke) your permission at any time. You can do this by sending the Chief Executive Officer at River City written letter.

 

5.      Exceptions

There may be times when we are unable to obtain your authorization and it is necessary for us to use or disclose your information. In this event, we will only release necessary information. Examples of when your PHI might be released without your authorization includes:

·         Emergency medical treatment

·         Medical treatment or care required by law

·         Suspected abuse and neglect of children and incapacitated adults

·         Reportable incidents to the public health authorities to help stop the spread of diseases

·         If you are believed to represent a threat to the safety of yourself or others

·         If requested by licensing organizations such as the Department of Behavioral Health and Developmental Services, Department of Medical Assistance, etc.

·         In the case of death we must report to the coroner and notify the organ bank

·         Worker’ Compensation (only pertaining to the injury relating to the compensation)

·         Reports to the Food and Drug Administration regarding consumed products

·         May permit access to information to students, contracted agencies for the Department of Health and Human Services and others who are conducting research activities which have been approved by Administration

 

6.      Your Rights

 

·         You may contact the Chief Executive Officer if you want more information about your Privacy Rights or our Privacy Practices or are concerned that we have not followed our own rules. You may also file a written complaint with the Director of the Office for Civil Rights. This information is readily available upon request and we will not retaliate against you if you file a complaint of any kind.

·         You may request access to your PHI. All reviews are supervised. You may receive a copy of your record for a reasonable charge. We will provide a copy of your discharge summary free of charge.

·         You may request that we amend your records. We will comply with your written request or respond in writing if we do not feel that an amendment is appropriate. You have the right in either case to add your own addendum to the records. A copy of this addendum will be released whenever we release copies of your record.

·         We will accommodate within reason any written request that asks us to communicate with you by a different means of communication or at a change of address.

·         You may request a list of recipients to whom your PHI may be released for purposes other than treatment, payment, and operations. You are entitled to one free “accounting” per 12-month period. There will be a reasonable cost for additional requests.

·         You must receive a copy of this notice of Privacy Policies.

·         You may ask, in writing, to restrict the use and disclosure of your PHI. We cannot promise to grant every written request, but in the event that the request is granted, you must abide by the agreement.

·         If you wish to give us access to you after you leave a hospital or other medical treatment facility, please do so in writing.

 

7.      Effective Date

 

These requirements are effective as of April 14, 2003. We reserve the right to change the terms of this notice at any time. If we do so, we will place the updated version in the waiting areas and on the River City website. You may also receive a copy of the updated notice from the Chief Executive Officer.

 

Client Satisfaction – 12 VAC 35-106-620. Monitoring and evaluating service quality.

 

            River City performs both face-to-face and written surveys to see how you feel about the services you are and have received. Questions are about access, quality, and appropriateness. Your participation is voluntary; however, we strongly believe that your voice is the best way to improve the system. Therefore, we hope that if you are contacted, you will take the time to respond.

 

General Policies and Procedures

Hours of Operation – 12 VAC 35-105-690. 

Community-based Service Hours: 365/24/7 days weekly

Mental Health Clinic Hours:
 
Monday-Friday:
 
9:00am-5:00pm
 
 
Phone:
 
1-804-230-0999
 
 
Emergency Phone:
 
911
 
 
River City Office Hours
 
Monday-Friday:
 
9:00am-5:00pm
 
 
Phone:
 
1-804-681-2525
 
 

Access to After-Hour and Emergency Services – 12 VAC 35-105-540. Access to telephone in emergencies; emergency telephone numbers.

 

River City defines an emergency or crisis as: “A Situation in which a client presents an immediate danger to Self or Others or is at risk of serious Mental or Physical Health deterioration.”

 

Medical Emergency is an injury or illness that is acute and poses an immediate threat to a person’s life or long-term health.

 

Psychiatric Emergency: Symptoms and conditions behind psychiatric emergencies may include attempted suicide, substance dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks, and significant, rapid changes in behavior. These behaviors are self-injurious, assaultive, or cause serious property damage and other severe behavior problems that are pervasive and maladaptive for which instructional/behavioral approaches specified in the Client’s ISP are found to be ineffective.

 

In an Emergency:

 

·         Call 911 for assistance if the emergency is life threatening, or may result in immediate physical harm to another person or yourself; then IIH and MHSS clients please call your River City Counselor.

·         Mental Health Clinic clients please call the general response number 804-230-0999 and your River City clinician will contact you within 30 minutes.

 

Important Numbers: All important numbers will also be posted in each facility based program.

 

            Fire 911

            Police 911

            Ambulance 911

            Police Non-Emergency 748-1251 OR 748-1431

            Poison Control 1-800-222-1222

            RBHA Crisis Hotline 1-804-819-4000

            Henrico Crisis Hotline 1-804-261-8484

            After-Hours Local Crisis Hotline 1-804-966-2496

            National Suicide Crisis Hotline 1-800-784-2433

            Richmond Department of Social Services 1-804-646-7212

            Henrico Department of Social Services 1-804-501-4001

            Richmond Department of Social Services- Family Violence Intervention Program 1-804-646-7183

            Virginia Family Violence and Sexual Assault Hotline 1-800-838-8238

            Disaster Relief (American Red Cross) 804-780-2250

 

Behavior Management Philosophy and Policy – 12 VAC 35-105-800. Policies and procedures on behavior management techniques.

 

            River City’s philosophy and policy regarding behavior management techniques focuses on assisting the client to access their innate abilities or those taught to manage their own behaviors. We believe that each client has the ability to modulate their emotional states for improved behavioral outcomes with or without River City assistance and support.

           

            River City will always utilize the least restrictive method of assisting a client in managing their behavior and gaining self-control in their life. We wholeheartedly believe that the Client and collective relationships that we foster lay the groundwork of mutual respect and trust for this to happen.

 

            Physical restraint will only be used to control unpredictable behavior, which poses clear and present danger of serious physical harm to the individual or others or serious property damage and which cannot be immediately prevented by a response less restrictive than the temporary application of a technique used to contain the behavior. In the event that a physical restraint becomes necessary, staff will only implement Crisis Wave, a noninvasive restraint in which all staff are fully trained to safely implement. The Management Team will be contacted immediately and a report will be filed for the client’s file. Further assistance such as Police may be notified depending on the severity of the incident.

 

Weapons Policy – 12 VAC 35-105-310. Weapons.

 

            Weapons of any kind are strictly prohibited while you are receiving services from River City. You may not have any type of weapon in our facilities, on our grounds, within 500 feet of our facilities and grounds, or while receiving services in the community. If it is suspected that you have a weapon or item that may used as a weapon River City staff will ask you to store this item elsewhere and/or contact the Police, if necessary.

 

Tobacco-Free Environment Policy

 

            River City offices are tobacco free environments. We want to maintain an attractive facility for everyone and assist you with achieving and maintaining your health. There is no smoking in the front or sides of our building. A designated smoking area with smoke receptors will available for you to use as needed or applicable to your program. If you are interested in a smoke-free lifestyle, please speak to River City staff for assistance with smoking cessation strategies.

 

Emergency Preparedness – 12 VAC 35-105-530. Emergency preparedness and response plan.

 

            The primary purpose of River City’s Emergency Response Plan is to establish a strategy that ensures the safety and well-being of clients receiving services and our employees in the event that an emergency occurs. Our Management Team stays abreast of national, state and local news and works with local authorities to coordinate our Emergency Preparedness Plan. We also ensure that our employees maintain a state of readiness and ability to respond to emergencies through training and development initiatives. In the event of an emergency, i.e. flood, hurricane, severe weather, your assigned River City staff will contact you with instructions (Community-Based) and/or an “emergency message” with instructions will be available at 804-230-0999 (Facility Based).

 

Please note: River City Staff are available 24-hours daily, 7-days weekly and 365-days yearly for your health and wellness.

 

Building Layout and Evacuation Plans – 12 VAC 35-105-690. Orientation. 12 VAC 35-105-280. Physical environment.

 

            Every building and facility used by River City will have appropriate building layouts and evacuation plans clearly displayed in open areas. All buildings and facilities will be handicapped accessible and will be an environment conductive to treatment. Routine fire, evacuation, and emergency drills will be a part of residential programs and all staff and clients will be made aware of proper routes for evacuation of a building in case of emergency in our facility based programs. In the event of any emergency, clients will evacuate the building according to the evaluation plan. Staff will ensure the safety of all clients and call 911 or other appropriate emergency numbers.

 

Inclement Weather Policy

 

            When the weather is severe enough that Richmond Public Schools (RPS) cancels school, certain programs facilitated by River City will be cancelled. This includes individual as well as group therapists. The Veterans Employment Program offices will also be closed. Clients can call the office at 804-230-0999 by 8:00 AM to confirm the list of services that will be cancelled. Community-based programs such as intensive in-home and mental health support services will continue as scheduled with potential modifications. Residential programs will also continue as scheduled with potential modifications to the daily schedule.

 

Financial Policy

 

            River City programs accept the following payment methods for services: self-payment, Medicaid, state financed insurance (other than Medicaid), private health insurance and military insurance (e.g., Va., Tricare) as forms of payment, as well as VISA, MasterCard, and personal checks. A sliding fee scale (fee is based on income and other factors) is also available for payment assistances if applicable.

 

            You may use your insurance to pay for services or you may choose to pay out of pocket for your treatment. Some patients have no insurance and pay for treatments themselves. You may be responsible for paying your co-payments while you are attending the program. To find out the cost of this option, make financial arrangements, and payments prior to starting the program, you would need to contact our Business Office at 804-230-0999.

 

Understanding Your Insurance Benefits

 

            You will meet with the Business Office prior to your intake assessment so that they can determine your insurance benefits and help you plan your financial options. Feel free to ask about any concerns you have regarding financial matters.

 

            Most medical insurance plans require pre-certification, meaning that the particular insurance company must be contacted prior to services and given clinical information to determine if services meeting their criteria for treatment. Each insurance company has their own policy. Many insurance companies have contracted with another company that specializes in managing access to treatment, and this company can approve, decline, and limit the treatment for which they are willing to pay. When you come into the program, if they approve your participation, they usually give authorization for you to come for a specific amount of time, typically 1 to 10 days initially and will then schedule a date to review your progress and determine whether you can continue with services. The Business Office manages all these calls for authorization. If you have questions about insurance authorization, please contact your Clinical Care Manager.

 

Pricing for Services – 12 VAC 35-105-230. Written fee schedule. 12 VAC 35-105-240. Policy on funds of individuals receiving services.

 

            As stated in the Client Bill of Rights and Responsibilities, it is your right to understand all of your financial charges or potential charges as it relates to your case. We do not supply specific information related to service billing in this handbook as all service prices are subject to change according. Please see your direct care worker, program manager, to contact the office directly for specific pricing information.

 

Release of Liability – 12 VAC 35-105-220. Indemnity coverage.

 

            As a voluntary participant of River City Programs, you have signed a release of liability to include transportation, consent to search, proper use of restraint, photography of clients, and use of medical care as necessary. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for this event. The undersigned further agrees to abide by all the rules and regulations promulgated by River City and/or its affiliate groups and vendors.

 

Staff Introductions

 

            Upon intake, each client will be introduced to their assigned Staff Member, Group Administrator, or Therapist. Contact numbers of applicable and appropriate staff will be given to every client in order to schedule appointments, arrange transportation, or to assist with crisis emergency situations.

 

Closing Word

            On behalf of the staff at River City Integrative Counseling Service, Inc., we wish to thank you for choosing our services. Whether you are an adult, child or parent, we aim to offer you comprehensive services specifically tailored to meet you individual needs. We believe the client comes first and are dedicated and committed to working with you side by side to deliver the most effective treatments that will allow you to live the best life possible.

 

            We hope that this handbook has answered some of your questions regarding programs and services offered by River City Integrative Counseling Services, Inc. Your interest, involvement, and participation will be key to your continued success. We look forward to working with you to meet all of your treatment goals.

 

 

 

Please check the box next to the following statements that you have read, understand, received, and attest to the corresponding sections of the client intake packet:

I, the undersigned, agree to the contents contained within the River City Integrative Counseling’s client intake packet.