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You will be provided with a copy of your Initial and Individual Treatment Plans. Your clinical record is the property of Sigma Center for Counseling and may be available for your review. A written request is required to get copies and the cost is $1.00 per page. Clinical Records are maintained for seven (7) years.
There is a $35 fee to print and send your complete record to whom you designate in writing. Allow two weeks for the process.
The following forms are included for your reference only. You will be asked to complete and sign a copy for our files during your first appointment. Please review these forms to ensure that all necessary information is available.
Table of Forms
· Informed Consent for Assessment and/or Treatment
· Informed Consent for Testing
· Informed Consent for Research
· Limits of Confidentiality Policy
· Financial Agreement
Informed Consent for Assessment and/or Treatment
TO THE CLIENT: You have the right, as a client, to be informed about the results of assessments performed, the nature of identified conditions, and any recommended treatments for identified conditions so that you may make an informed decision whether or not to participate in treatment.
POTENTIAL BENEFITS: The long-term benefits of participating in a substance abuse intervention or treatment program include possible improved functioning in various life areas and an improvement in overall physical health.
POTENTIAL PROBLEMS RELATED TO RECOVERY: Some clients will experience withdrawal symptoms. The reduction or cessation of prolonged heavy use of alcohol and drugs may be followed by heavy tremors and a number of the following symptoms: nausea or vomiting, malaise, tachycardia, transpiration, increased blood pressure, anxiety, depression or irritability, passing hallucinations or illusions, headache, sleeplessness. As the result of the interaction of biological, psychic and environmental factors, alcohol or drug withdrawal delirium can occur resulting in: reduced level of consciousness, disorientation, memory disturbances, delusions, and hallucinations (usually visual) with very restless and agitated behavior. Alcohol hallucinosis can also occur, which is characterized by lively acoustic hallucinations while the consciousness remains clear.
LIKELIHOOD OF SUCCESS: Clients participating in some form of substance abuse intervention or treatment show significant and sustained improvement in increased percentage of abstinent days and decreased number of drinks per drinking day. Studies report relapse rates of more than 50 percent or more at two to four years after treatment. Studies also estimate that more than 50 percent of treated patients relapse within the first 3 months after treatment.
THE POSSIBLE RESULTS OF NON-TREATMENT: Untreated alcohol and/or drug problems may result in a variety of medical complications including but are not limited to: an increased risk of the emergence of carcinomas in the upper part of the digestive system, gastritis, stomach ulcers, acute, recurrent and chronic pancreatitis, hepatitis, cirrhosis, cardiomyopathy, and arrhythmia. A reduction in the elimination of uric acid could lead to the onset of gout. Sleep disturbances in the sense of a changed sleep structure, earlier waking and suppression of REM sleep (when dreaming is done), complications due to withdrawal symptoms and the potential for Fetal Alcohol Syndrome (FAS) in new births. Death. There may also be increased behavioral and legal problems related to the continued alcohol and drug consumption.
ALTERNATIVES: Information about local self-help programs is available from your counselor. Some referral sources require counseling and may not recognize a self-help program as satisfying the requirement for counseling. You may elect to attend a self-help program that will meet your needs.
THE NAME OF COUNSELOR WHO HAS PRIMARY Responsibly FOR YOUR CARE: Sigma Center for Counseling, assumes primary responsibility for your substance abuse treatment care in a multidisciplinary team. Your primary counselor ________________________, he/she will serve as your advocate and deliverer of substance abuse treatment services.
ATTESTMENT:
I understand that no guarantee has been made to me about the results of substance abuse treatment. I voluntarily request Sigma Center for Counseling to evaluate my substance use and to provide treatment for any identified substance related problems.
Informed Consent for Testing
Urine/Saliva and/or Breath Screening for Drugs and/or Alcohol
I agree to provide urine/saliva and/or breathe samples for testing upon request, to help confirm whether or not I am using drugs including alcohol and marijuana. I understand that a staff person of the same gender may observe me providing this specimen. These results will be used for the expressed purpose of monitoring substance use as prescribed by the treatment plan.
I understand that test could be conducted at the request of my primary counselor at any time, while receiving services at this level of care.
I understand that the results will be shared with me, my treatment team and may be discussed in group. I may designate others to have my screening results by completing a separate consent for release of information form.
I also, understand that I will have to demonstrate an ability to remain alcohol and/or illegal drug free for a period of 30 consecutive days prior to my discharge from the program.
Informed Consent for Research
From time to time, Sigma Center for Counseling will collect and conduct research connected to the services we provide. Our only reason for conducting this research is to analyze, improve and to ensure that we are providing evidence-based, professional services.
Our code of ethics requires that you be informed when your information and data are used in this process. At the present time we are collecting data at admission and discharge through tests and surveys. We are also collecting information to prove the effectiveness of our open-ended group and our close-ended group as it relates to the recidivism rate of individuals arrested and convicted of DUI. You will be asked to sign an informed consent for any other research requirements.
At no time will any personal identifying information be used or published in connection with any research performed at Sigma Center for Counseling.
Limits of Confidentiality Policy
Confidential communication remains the right of all clients of professional counselors according to law. However, there are limits to such communication some of which are mandated by state law. It is very important that you and those seeking counseling with you carefully read and understand the following limits of confidentiality.
Duty to Warn
Some courts have held that if an individual intends to take harmful, dangerous, or criminal action against another human being, or against himself or herself, it is the counselor's duty to warn appropriate individuals of such intentions. Those warned may include a variety of persons such as:
1. Law enforcement and medical emergency officials.
2. The person who is likely to suffer the results of harmful behavior.
Child Abuse
Florida state law mandates the reporting of incidence or suspected incidence of child abuse including physical abuse, sexual abuse, unlawful sexual intercourse, neglect, and emotional and psychological abuse. All actual or suspected acts of child abuse will be reported to the appropriate agencies.
"Dependent Adult" and Elderly Abuse
Florida law requires that incidences of ?dependent adult? or elderly physical abuse reported to your counselor must also be reported to authorities.
Case Evaluation
In order to ensure the best treatment possible for each client, staff at Sigma Center for Counseling will consult with each other regarding cases. This is traditional in both out?patient and in-patient counseling facilities and is referred to as "case conference" or "peer review." If you have any concerns regarding this practice, please notify your counselor.
Confidentiality in Group
Confidentiality in the group setting is of the utmost importance. It is imperative that all participants in group feel free to express their thoughts and feelings without fear of repercussion. Any information shared in group should stay within the group. If legal reporting is required, it will be handled by the counselor in charge. Anyone disregarding this policy will be dismissed from group and potentially from treatment. Sigma Center for Counseling cannot be held responsible for information shared in the group setting; however we are dedicated to ensuring dignity and respect for every client.
Neglect of Outstanding Debt
In the event that a client fails to honor (after reasonable efforts to collect) his/her financial obligation, Sigma Center for Counseling may place the account in the hands of an agency or attorney for collection or legal action. This will necessitate the release of pertinent demographic information as well as accounting information. NO THERAPEUTIC INFORMATION WILL BE RELEASED.
Please be sure that you have read the above very carefully. If you are not sure that you fully understand any of the above areas of confidentiality limitations, please ask your counselor before you sign below.
I, the undersigned, have read and fully understand the limits of my/our confidentiality. I further agree to abide by the policy set out above. I have had a chance to ask my/our counselor for additional clarification regarding the limits of confidentiality.
FINANCIAL AGREEMENT
The following constitutes an agreement between the undersigned Client or guarantor and Sigma Center for services rendered by staff of Sigma Center for Counseling.
ACCEPTANCE OF FINANCIAL RESPONSIBILITY
I accept responsibility to pay by cash, check or money order before each service is rendered. I also, understand that a $35.00 fee will be assessed for all returned checks. The second returned check will be turned over to the District Attorney for issuing fraudulent checks.
I understand that I can file for insurance reimbursement and that Sigma Center for Counseling will provide the necessary information concerning my treatment required by my insurance company.
MISSING APPOINTMENTS / GROUPS
I understand that if I have an appointment and fail to cancel it at least twenty-four hours in advance, during the business hours of this office that I will be charged for the service that was scheduled to be delivered. Additionally, a missed appointment fee will be charged to my account.
I agree to pay a non-refundable fee of $50 if I fail to contact the office when I will miss a scheduled appointment or group meeting. ____________
REQUEST FOR FINANCIAL ASSISTANCE
____ By checking this box, I believe that my family and I will suffer a hardship paying for this program and request to have my case reviewed to see if I qualify to receive these services on a sliding scale. I understand that an in-depth financial analysis will be conducted requiring that I present proof of all my financial information. I will make a copy of my credit report available for review. I also, understand that my finances will be addressed in my treatment plan.
UNDERSTANDING OF FINANCIAL RESPONSIBILITY
I elect to enter into this agreement freely and understand that I am financially responsible for all services provided.
All outstanding balances must be paid in full before any completion documentation is processed.
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