CLIENT INFORMATION

RCIC Outpatient Intake Packet 2/16/22

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.

RCIC Outpatient Intake Packet 2/16/22

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.

RCIC Outpatient Intake Packet 2/16/22

River City Integrative Counseling Services will be offering all outpatient therapy services either face-to- face or via telehealth. Our telehealth services will be provided using google hangouts which is a HIPAA compliant audio/video software. Our clients who may not have access to a computer or a smart phone, will be eligible to receive all outpatient therapy services over the phone. In order to ensure that our clients get the care and services they need, during this state of emergency, we are working collaboratively with our insurance payers to ensure the appropriate reimbursements occur.

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.

I, the undersigned, agree to the contents contained within the River City Integrative Counseling’s COVID-19 addendum.

RCIC Outpatient Intake Packet 2/16/22

COUNSELING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist who has the desire and willingness to help you accomplish your individual goals. Counseling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counseling, there may be periods of increased anxiety or confusion. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. Your therapist is available to support you throughout the counseling process.

All interactions with River City Integrative Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential. You may request that the counseling staff release specific information about your counseling to persons you designate.

EXCEPTIONS TO CONFIDENTIALITY:

• best possible care. These consultations are for professional and training purposes.

The counseling staff works as a team. Your therapist may consult with other counseling staff to provide the

• to report this information to the authorities responsible for ensuring safety.

If there is evidence of clear and imminent danger of harm to self and/or others, a therapist is legally required

• physical or sexual abuse or neglect of any person under 18 years of age must report this information to county child protection services.

State law requires that staff of River City Integrative Counseling Services, who learn of, or strongly suspect,

• information contained in records and/or require a therapist to testify in a court hearing.

A court order, issued by a judge, may require the River City Integrative Counseling Services , staff to release

We appreciate prompt arrival for appointments. Please notify us at 804-681-2525 if you will be late. Twenty- four-hour notice of cancellation allows us to use the time for others.

I have read and discussed the above information with my therapist. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a client of the River City Integrative Counseling Services.

RCIC Outpatient Intake Packet 2/16/22

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 FOR A MAXIMUM OF 90 DAYS AFTER I SIGN AND DATE THE FORM BELOW, UNLESS THE PURPOSE OF THIS AUTHORIZATION IS TO MAINTAIN ONGOING COMMUNICATION IN ORDER TO ENHANCE CONTINUITY OF CARE, IN WHICH CASE IT WILL REMAIN CURRENT THROUGHOUT THE DURATION OF ENROLLMENT AND EXPIRE 90 DAYS FROM THE DATE OF DISCHARGE FROM SERVICES. 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.

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

If you are subjected to your deductible here are our Contracted Rates with your payer:

PAYER            Assessment     Follow-up

Anthem           $134.62         $130.95

Cigna              $98                $95.00

Aetna              $71.30           $71.30

Tri Care           $125              $100

United/Optum  $125              $100

Self-Pay           $125             $100

RCIC Outpatient Intake Packet 2/16/22

PRINT AND COMPLETE THIS AUTHORIZATION AND

RETURN. All information will remain confidential

(last 3 digits located on the back of the credit card)

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

• Care Coordination: Behavioral Health Clinician and Primary Care Physician Consent or Refusal

• Policy: Attendance, Cancellation, Insurance and Payment, & Credit Card • Release of Liability

• COVID-19 Addendum

• Client Consent

• Release of Information: We do not release any information without a signed release
except in the case of a court subpoena or as requested by your insurance company or
referral/funding source.

• Schedule of Fees

• Authorization for Credit Card Use

• Program and Client Handbook

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

• Grievance Policy: Human Rights Policies and Reporting Violations

• Notice of Privacy Practices: Protected Health Information

• General Policies and Procedures: Hours and days of operation, Emergency contact numbers, After-hour services, Weapons, Tobacco, Inclement weather, Financial and Fee for service policies

• General Policies and Procedures: Behavior Management Policy

• General Policies and Procedures: Emergency Preparedness and Fire Safety

• General Policies and Procedures: Building Layout and Evacuation Plans Program Specific Policies and Procedures: Program Handbook/Parental Support

• Program Specific Policies and Procedures: Urine Drug Screening Policy/Procedures

• Staff Introduction and Contact Information

Philosophical Evolution, Mission, and Vision – 12 VAC 35-105-570

River City Comprehensive Counseling Services, Inc. (RCCCS) was established in 2009 and has been committed to providing quality behavioral health services for individuals ages 5 to older adults who experience emotional, mental, behavioral, and/or substance abuse conditions that negatively impact their lives. Our comprehensive, structured programs of care are designed to promote recovery by improving psychiatric symptoms, preventing relapse, teaching functional life skills, providing direct assistance and psychosocial support, and assistance accessing vital community resources necessary for successful functioning in home, work, school, and social relationships. A multi-disciplinary team of health professional provides superior psychiatric and addiction services while respecting participant dignity and rights.

River City Comprehensive Counseling Services, Inc.

River City’s successful vision is providing a comprehensive integrative continuum of community-based medical, psychiatric, and substance use treatment services that are client-driven, family-focused, and promote recovery from any psychosocial or behavioral problem.

Intensive In-home Services (IIH): Intensive home and community-based treatment (approximately 10 hours weekly) for individuals ages 5-21 that focuses on preserving the family system by providing interventions to at-risk individuals 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. Concurrent psychotherapy with the provider of the client/family’s choice is also a requirement to receive IIH services.

Mental Health Skill-Building Services (MHSS): Intensive home and community-based treatment (9-15 hours weekly, dependent on Managed Care Organization/insurance provider) for individuals ages 17-older that focuses on assisting individuals to maintain community stability and independence through developing/implementing independent living skills, resource management, and monitoring of psychiatric and medical care in congruence with treatment goals. The goal of services is to prevent hospitalizations or higher levels of care, homelessness, and incarceration by enhancing the individual’s coping and adapting skills.

Community Stabilization (Non-residential): Community Stabilization is designed for individuals experiencing a severe, acute decline in their mental and emotional well-being that puts them at risk for or has resulted in out of home placement. It is intended to prevent hospitalization or re-hospitalization by providing a stable environment with a high level of support services. Individuals participating in Community Stabilization will receive 7 consecutive days/up to 4 hours per day of individual counseling, 24-hour on call support, and will be connected to community resources to meet their immediate needs that contributed to the initial crisis.

Substance Abuse Intensive Outpatient Program (SA IOP): This ASAM Level 2.1 highly structured program utilizes Licensed Clinicians (LPC, LCSW), Certified Substance Abuse Counselors (CSAC), and Peer Recovery Specialists (RPRS) to provide clinical group individual, and family therapy between 19-hours (max) and 9-hours for adults or 6-hours for “young adults” (adolescents age 18-21SA IOP will supply a therapeutic environment including counseling and rehabilitative therapies, integrated psychiatric and medical treatment, Medication Assisted Treatment (MAT), Primary medical care (PCP), community- based case management, and recovery support services to meet the holistic needs of our patients. In addition to urine drug screening, Medication Management, & MAT, SA IOP staff will remain on-call 24hrs/7days per week to provide SA Crisis Intervention coverage outside of daily program hours.

Substance Abuse Case Management (SACM): River City’s SA IOP program utilizes CSAC-A’s to provide SA Case Management services assisting our patients and their family members in accessing and coordinating needed services including specialist medical, psychiatric, and psychological treatments as well as social, educational, vocational, pre natal, veterans employment, and recovery supports in the community essential to meeting their basic needs. Incorporating person-centered, individualized, culturally and linguistically appropriate approaches based on identified patient and family member's needs, CSAC-A Case Managers will maintain consistent communication and involvement to ensure the consistency and effectiveness of ASAM’s integrative multidisciplinary treatment philosophy including: a) sharing of important clinical information between participating providers on behalf of individuals and families; b) accompanying / advocating for individuals when necessary to strengthen engagement of participant with all multidisciplinary service providers involved; and c) working together to keep individuals and their families involved and informed throughout community reintegration.

River City Integrative Counseling, Inc.

Outpatient Therapy (OP): River City’s unwavering commitment to facilitating holistic recovery within community-based care through wrap-around service provision fueled dynamic organizational growth. Strategic leadership, creative ingenuity, and continuous quality improvement forged River City Integrative Counseling (RCIC) – our flagship Outpatient practice committed to integrating behavioral health into primary care.

River City Residential Services, LLC

Residential Services: RCRS incorporates peer recovery specialists to provide 24-hr. (ASAM L3.1) Clinically Managed Low-Intensity Residential Treatment for substance use and co-occurring disorders. Provided In in a smaller traditional behavioral health home setting instead of a hospital or psychiatric facility, this transitional residential service includes 5 hrs./week of on-site clinical treatment in combination with peer recovery supports providing a cost-effective alternative, which can be combined with SA IOP/OP services as needed.

Our goal is to forge a model program for efficient delivery of integrated substance abuse, psychiatric, and primary healthcare treatment services that raises local quality standards and promotes the following patient outcomes:

1. 2.Maintain extended abstinence, prevent relapse, and engage in active long-term recovery. 3.Provide healing for underlying emotional wounds, grief, and painful trauma from past experiences that perpetuates substance abuse. 4.Promote disease self-management through mastery of advanced mindfulness skills increasing frustration tolerance and independence. 5.Promote systemic healing in families through warm familial engagement in treatment to rebuild protective and positive natural supports.

Increase personal insight, learning, and applying recovery skills.

River City takes pride in providing quality community-based services, substance abuse care, and therapy. Our team of licensed clinical social workers and professional counselors, licensed-eligible mental health professionals, certified substance abuse counselors, and other qualified mental health professionals are available for your needs. We believe that addiction is a chronic relapsing disease that requires individually tailored therapeutic treatment, relapse prevention, and recovery strategies that look different for each person to be successful.

River City’s Structured Program of Care is defined as a comprehensive and planned daily, weekly, monthly routine including appropriate supervision that meets the needs of the client and their family (if applicable), that includes, but is not limited to:

ASAM Multidimensional assessment / diagnostic evaluation Comprehensive Needs Assessment Individualized Service Planning Group Counseling including:

• Addiction & Mental Illness Psychoeducation o Mindfulness Skills Training
• Relapse Prevention Therapy / Interactive Feedback Individual Psychotherapy Family Counseling and Therapy Integrated Psychiatric / Medical Care – Dr. Peter Breslin, Addiction Psychiatrist
• Medication Assisted Treatment (Vivitrol & Buprenorphine – referrals to OTP)
• Urine Drug Screening
• Interdisciplinary Trea tment Team Meetings
• Crisis Stabilization
• Skill Building
• Recovery Support Services
• Care coordination
• Discharge Planning
• Substance Abuse Case Management

My signature on the orientation checklist indicates that I have reviewed, clearly understand, and am providing informed consent for all necessary release / sharing of Protected Health Information between my River City treatment team of interdisciplinary providers and staff members at their discretion across all services in the aforementioned description including:

River City Comprehensive Counseling, Inc., River City Integrative Counseling, River City Residential Services, LLC Verity Psychiatry – Dr. Peter Breslin, MD Dr. Laura Toombs, MD (PCP) True Recovery, RVA Journey House Foundation, LLC Recovery Community Organizations VASAP and ASAP Offices

Client Bill of Rights and Responsibilities - §150. Compliance with applicable laws, regulations and policies. Every client receiving services from River City Comprehensive Counseling, Inc., River City Integrative Counseling, and/or River City Residential Services, LLC has inherent rights and responsibilities. These Client Rights and Responsibilities are discussed during the assessment/admission process, distributed to clients via this Program and Client Handbook and are posted in all 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, your understanding of these client rights and responsibilities, and other important aspects of your health care.

• 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.

• 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 - §130. Confidentiality of records; §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 your written authorization, unless compelled by law (including court orders, medical emergency, insurance inquiry or requests for subsequent authorization of services, 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 file in a locked room and/or maintained electronically in accordance with HIPAA regulations.

Access to Information and Records

• representative 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.

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, handicap, 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.

The right to humane care and protection from harm. Staff members 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.

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. 

• 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 of 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.

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

Consumer Advocate: Questions, Concerns, Complaints, or Grievances (see page 8 for explanation of these terms)

• The right to have your questions answered, to make complaints about services you receive, violations of these rights, and to have those complaints heard and addressed 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.

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*. (*Medicaid 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. • If a client meets the criteria for “failed services” (as set forth by DMAS and defined as the services not effectively treating or resolving the client’s mental health and/or behavioral issues within a certain timeframe), they have the right to be referred to an appropriate or alternative level of service.

If you feel, at any time throughout your treatment, that your rights have been or may be violated, you may ask questions, file a complaint or discuss the matter with the Program Director, Chief Clinical Officer, CEO, or human rights program advocates listed in this handbook in the Grievance section. These individuals are program supervisors ethically committed to protecting your human rights and providing nonjudgmental guidance / assistance in navigating the complaint resolution process. If you feel that you need additional, outside assistance concerning your rights, you may contact the Regional Advocate for Human Rights for Region 4: Sharae Henderson – 804-524-7479.

Client Responsibilities

• Provide accurate and complete information about your past illnesses, hospitalizations, medications, 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. • Conduct yourself in an appropriate manner. Rule violations or behaviors that interfere with the treatment process 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 the influence of intoxicating beverages or illegal substances; 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, harass, coerce, or interfere with other people;6) falsify information provided to River City; or 7) smoke inside any River City facilities. Services may also be limited or terminated if a client fails to keep their scheduled appointments.

Transportation Medicaid will only reimburse for services provided as defined as clinically necessary in the client’s ISP. To promote independent living skills and long-term community stabilization after these time-limited services are no longer deemed clinically necessary, River City provides coordination of transportation assistance which may include connection to agencies licensed to provide transportation assistance (e.g., care vans) to medical appointments and activities required for the client to access/utilize public transportation. Ability to access transportation services is determined by your MHC and clinical treatment team. We do not unfortunately provide clients with bus tickets or any other form of financial assistance. River City is not a Non-Emergency Medical Transportation (NEMT) provider. 

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 providers 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. By signing the corresponding Freedom of Choice Statement below and after carefully reading and having River City explain this document, you attest that neither you nor your dependents have been coerced, bribed, offered money or favors for requesting services and choose to participate in services offered by River City Comprehensive Counseling Services, Inc., River City Integrative Counseling, and/or River City Residential Services, LLC.

• By signing the Orientation Checklist, I am making the decision/choice under the DMAS’ Freedom of Choice provision, which includes both my freedom to choose and/or reject services from any provider participating in the Medicaid program. Under this provision, I request services from:

River City Residential Services, LLC - NPI#1508487901 River City Comprehensive Counseling Services, Inc. - NPI#1729225246, 1811237761 River City Integrative Counseling Services, Inc. - NPI#1619369444

I attest that I have not received any compensation in exchange for my request to participate in services with River City and am choosing to do so without being solicited, coerced, bribed or threatened in any way to sign this document. I acknowledge that River City has made all reasonable attempts to educate me regarding my rights to choose a provider(s).

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 - §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 or 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 to 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 counselor/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 counselor’s/case manager's decision, then the client will have the right to raise a formal grievance with the next level of Management within two work days of the supervisor’s/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 manger’s decision. The Management Team will schedule a meeting within three business 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 business days. Step 3: Human Rights Advocate This is the highest level within the Company's appointing authority. The management team (in step 2) will advise the Human Rights Advocate who will review all documents pertaining to the incident. The Human Rights Advocate will provide the client with the company’s decision in writing within two business 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 Local and State Human Rights Committee, if necessary.  

Your River City Human Rights Advocates are:

Community-based Services (IIH, MHSS, CS): Alison Youmell, LCSW 804-230-0999 x186

Substance Use Services (SA IOP, SACM): Tangee Augustin, LCSW 804-230-0999 x499

Residential Services: Alex McClelland, LPC 804-230-0999 x457

Outpatient Services: Madison Cully, 804-681-2525

Chief Operations Officer: Tonita Christmas, 804-230-0999 x120

The Local Human Rights Advocate is:

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

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

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 may 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 at any time, but you must do so in writing. Please note that revocation may affect our ability to provide you with services.

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:

Have specific authorization signed by you or your legally authorized representative

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 Clinical Officer of your program a written letter.

Exceptions to Obtaining Your Authorization

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:

• 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 D epartment 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 app roved by Administration

Emergency medical treatment Medical treatment or care required by law

• 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

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.

 These requirements were 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 office waiting areas and on the River City websites. You may also receive a copy of the updated notice from the Chief Executive Officer.  

Client Satisfaction - §620. Monitoring and evaluating service quality.

River City Counseling Group performs face-to-face, telephone, 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.

Hours of Operation - §690. Orientation.

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

Residential Treatment Program Service Hours: 356/24/7 days weekly

Monday-Thursday: 8:30am-5:00pm (later by appointment) Friday: 8:30am-12:00pm (later by appointment)

River City Comprehensive Counseling Services: www.rivercityccs.com

River City Integrative Counseling: www.rivercityic.com

River City Residential Services: www.rivercityresidentialservices.com

Access to After-Hour and Emergency Services - §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 placing them at immediate risk of out-of-home placement.”

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.

• Call 911 for assistance if the emergency is life threatening, or may result in immediate physical harm to another person or yourself;
• T hen please call your River City c ounselor, case manager, or program contact . If they are unavailable, you may contact the following general numbers: o River City Comprehensive Counseling Services: 804- 230- 0999 o River City Integrative Counseling: 804 - 681- 2525 or 804 - 230- 0999 o River City Residential : 804- 799- 9001; 804 - 799- 1993 (Hungary); 804- 799- 1478 (Putney)

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

Police 911 Ambulance 911 Richmond Police Non-Emergency 804-748-1251 or 804-748-1431 Henrico Police Non-Emergency 804- 501-5000 Poison Control 1-800-222-1222 RBHA Crisis Hotline 804-819-4000 Henrico Crisis Hotline 804-261-8484 After-Hours Local Crisis Hotline 804-966-2496 National Suicide Crisis Hotline 1-800-784-2433 Richmond Department of Social Services 804-646-7212 Richmond Department of Social Services – Family Violence Intervention Program 804-646- 7183 Henrico Department of Social Services 804-501-4001 Virginia Family Violence and Sexual Assault Hotline 1-800-838-8238 Disaster Relief (local American Red Cross) 804-780-2250

Behavior Management Philosophy and Policy - §800. Policies and procedures on behavior

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.

Physical restraint will only be used to control unpredictable behavior that poses clear and present danger of serious physical harm to the individual or others or serious property damage and that 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 non-invasive restraint in which all staff members are fully trained to safely implement. The Human Rights Advocate will be contacted immediately and a report will be filed. Further assistance such as police may be notified depending on the severity of the incident.

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 and Response Plan - §530

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, your assigned River City staff may contact you with instructions and/or an “emergency message” with instructions will be available at 804-230-0999.

Please note: River City Residential and Community Stabilization Staff is available 24 hours daily, 7 days weekly and 365 days yearly for your health and wellness.

Building Layout and Evacuation Plans - §690. Orientation; §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 conducive 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 evacuation plan. Staff will ensure the safety of all clients and call 911 or other appropriate emergency numbers.

When the weather is severe enough that Henrico County Public Schools (RPS) cancels school, certain programs facilitated by River City Comprehensive Counseling & River City Integrative Counseling will be cancelled. Clients can call the office at 804-230-0999 by

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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 - §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 Focused Outreach Richmond and/or its affiliate groups and vendors.

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.

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.

River City and Focused Outreach Richmond programs accepts 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 Office Specialist 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 - §230. Written fee schedule. §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 ofyour 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 - §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 Focused Outreach Richmond 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.

On behalf of the staff at River City Comprehensive Counseling Services, Inc., River City Integrative Counseling Services, Inc., and River City Residential Services, LLC, 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 your 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 Comprehensive 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.