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Community Counseling Center

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Community Counseling Center
CONFIDENTIAL CLIENT PA
PERWORK
Date of Birth:
Contact Information
(M)
Yes No
Today’s Date:
Full Name:
Social Security Number:
Telephone(s): (H)
May CCC Staff leave a voice message?
If Yes, please specify:
H
ome Mobile Work
Street Address:
City: State: Zip Code:
Emergency Contact – please include your emergency contact in your release of information form.
Contact Name:
Telephone(s): (H) (M)
Relationship:
Referral Information – what agency or person referred you to us.
Agency (if applicable):
Contact Name:
Telephone(s): (W) (M)
Street Address:
City: State: Zip Code:
Demographic Information – the questions below are for demographic purposes only. Please mark the appropriate category.
Race:
American Indian/Alaskan Native Asian or Pacific Islander Black/African American
White/Caucasian Multi-racial/Two or more races I prefer not to answer
Are you Hispanic, Latinx, or Spanish ethnicity? Yes No I prefer not to answer
If Yes, please answer the question below:
Mexican Puerto Rican Cuban Central American South American
Other:
How do you identify yourself?
Female Male Nonbinary Trans I prefer not to answer
Other:
If Female, please answer the question below:
Are you pregnant? Yes N
o
W
hat is your orientation?
Heterosexual/Straight LGBTQIA+ I
prefer not to answer
Other:
Are you currently employed? Yes No
If Yes, what is the name of your employer?
Do you have health insurance/Medicaid? Yes No
If Yes, what carrier?
Insurance/Medicaid Member ID/Recipient Number:
Have you ever used drugs intravenously? Yes No
If Yes, when was the last time you used?
Have you ever received services at this agency? Yes No
A
re you receiving services somewhere else? Yes No
If Yes, what agency?
Intake/Client Concerns
The following information will assist us in recommending a treatment program that will best meet your needs. This is
confidential information and will not be released without written consent. Please feel free to take your time in answering
the following questions.
1. What services does your referral source wish you to receive from CCC?
Comprehensive Evaluation Substance Abuse Assessment
Mental Health Assessment Stress, Impulse Control
Anger Management Recovery Group
Individual/One on One Addiction Education
NA/ Self-referred
2. What services do you wish to receive from CCC?
Comprehensive Evaluation (Substance Abuse/Mental Health Assessment)
Stress, Impulse, Anger Management Recovery Group
Addiction Education Individual/One on One
Marriage and Family/Couples Wellness
HIV Education/Counseling LGBTQ+ Support
Affirmations: LGBTQ+ Affirmative Counseling provided at the Center by CCC.
Case Management (Do you need help with food stamps, transportation, applying for Medicaid, etc.)
3. What topics are you interested in exploring with a counselor?
Drug/Alcohol Concerns Depression
Anxiety/Stress/Fear Job/Economic Concerns
Emotional Concerns Health Concerns
Relationship issues COVID-19/Pandemic/Quarantine
Other:
Comments - Please list anything that you would like to address with a clinician or case manager.
This form, like the rest of your file, is confidential and will only be used for treatment purposes.
Community Counseling Center – Client Rights and Policies
1. CLIENT RIGHTS AND RESPONSIBILITIES
These are universal rights for all clients attending any and all programs at our organization. Please take the time
to read them. As the client of a program for treatment of abuse of/or dependence upon alcohol or other drugs,
mental health, infectious disease or any other program offered at CCC, your rights include but are not limited to
the following:
• If the program received funds the Substance Abuse Prevention and Treatment Agency (SAPTA), you have the right
to be provided treatment regardless of whether or not you can afford to pay for it, and the program is prohibited
from imposing any fee or contract that would be a hardship for you or your family.
• You have the right to be provided treatment appropriate to your needs.
• If you are transferred to another treatment provider, you have the right to be given an explanation of the need
for such transfer and of the alternatives available, unless such transfer is made due to a medical emergency.
• You have the right to be informed of all program services, which may be of benefit to your treatment.
• You have the right to have your clinical records forwarded to the receiving program if you are transferred to
another treatment program.
• You have the right to be informed of the name of the person responsible for coordination of your treatment and
of the professional qualifications of the staff involved in your treatment.
• You have the right to be informed of your diagnosis, treatment plan, and prognosis.
• You have the right to be given sufficient information to provide for informed consent to any treatment you are
provided. This is to include a description of any significant medical risk, the name of the person responsible for
treatment, an estimate of the cost of the treatment, and a description of the alternatives to treatment.
• You have the right to be informed if the facility proposes to perform experiments that affect your own treatment,
and the right to refuse to participate in such experiments.
• You have the right to examine your bill for treatment and to receive an explanation of the bill.
• You have the right to be informed of the program’s rules for your conduct at the facility.
• You have the right to refuse treatment to the extent permitted by law and to be informed of the consequences of
such refusal.
• You have the right to receive respectful and considerate care.
• You have the right to receive continues care: To be informed of your appointments for treatment, the names of
the program staff available for treatment, and of any need for continuing care.
• You have the right to have any reasonable request for services reasonably satisfied by the program, considering
its ability to do so.
• You have the right to safe, healthful, and comfortable accommodations.
• You have the right to confidential treatment. This means that, other than exceptions defined by law-such as those
in which public safety takes priority-without your explicit to do so the program may release no information about
you, including confirmation or denial that you are a patient.
• Waiver of any civil or other right protected by law cannot be required as a condition of program services.
• You have the right as a prospective client to be treated without any delay expressly based on disability, race,
gender, religious orientation, sexual orientation, national origin, and/or ability to pay for services.
• Should you become a client, you further have a right to receive equitable treatment, not restricted in the
employment of any advantage or privilege enjoyed by others under the program or with any aid, treatment,
services, or other benefits which are different, or provide in a different manner from that provided to others under
the program specifically based on disability, race, gender, religious orientation, sexual orientation, national origin,
and/or ability to pay for services.
• You have the right to freedom from emotional, physical, intellectual, or sexual harassment or abuse.
• You have the right to attended religious activities of your choice, including visitation from a spiritual counselor, to
the extent that such activities do not conflict with program activities, the program shall make a reasonable
accommodation to your chosen religious activities. Attendance at and participation in any religious activity is to
be only on voluntary basis.
• You have the right to grieve actions, decisions of facility staff that you believe are inappropriate, including but not
limited to actions, and decisions that you believe violate your rights as a client. The facility is obligated to develop
a grievance procedure for timely resolutions of complaints from clients and to post such a procedure in a place
where it shall be immediately available to you. You have the right to freedom from retribution or other adverse
consequences as the product of filing a grievance. Clients have the right to register grievance about his/her
therapeutic treatment, the administration of rules, regulations, disciplinary measures, sanctions, and
modifications of rights to the Chief Executive Officer. The Grievance Procedures form will be available at the front
desk upon request. The Chief Executive Officer will investigate the grievance and will try resolving the issue within
ten (10) days of the compliant. If the issue cannot be resolved at the time, the Chief Executive Officer must
informed the President of the Board who will then appoint a grievance committee, who will consider the issue
and make recommendations to the Chief Executive Officer. Incident forms will be completed within 24 hours by
staff. The Substance Abuse Prevention and Treatment Agency will be notified within 24 hours of any incident that
may cause imminent danger to the health or safety of an employee of the agency, a client of the agency, or a
visitor. This Agency will also be notified of notified of any report of a regulatory agency relating to Community
Counseling Center, its physical plant, or its operations with 5 business days after Community Counseling Center’s
receipt of such report. Each step of transfer will be officially dated and documented by each recipient to
substantiate continuity in guaranteeing the rights of the client. If the client still does not feel that his/her grievance
has been resolved, he/she case to the Substance Abuse Preventions and Treatment Agency or Ryan White Part A
depending under which program you are receiving services.
• You have the right to file a complaint to your satisfaction, and the right to freedom from retribution or adverse
consequences as the result of filing a complaint. Such complaints may be addressed in writing or by telephone to:
Ryan White Part A
Clark County Social Service
1600 Pinto Lane, Las Vegas, NV 89106
(702)455-4270
Substance Abuse Prevention and Treatment
Agency
Statewide Program Coordinator
4126 Technology Way, 2
nd
Floor, Carson City,
NV 89706
1(775)684-4190
• You have the right to receive a copy of the signed version of this form, Clients Rights, plus the signed Consent to
Treatment and Confidentiality of Client Records Forms.
• You have the right to insert a written statement into your record.
• You have the right to be informed of your rights as a client. The foregoing are to be posted in the facility in a place
where they are immediately available to you, and you are to be informed of these rights and given a listing of
them as soon as is practically possible upon your beginning treatment.
2. NOTICE OF PRIVACY PRACTICES - How we protect the confidentiality of your health care records
This notice describes how medical information about you may be used and disclosed and how you can get success
to this information. Please review it carefully.
• What this notice does for you: This notice tells you the ways Community Counseling Center may use and disclose
medical/treatment information about you. It also describes you rights in regard to this information, and it details
certain obligations we have regarding the use and disclosure of this information. We are committed to protecting
your confidentiality treatment information. Furthermore, we require by law to make every effort to endure that
any health information that identifies you in any way is kept private. We are also required to give you this Notice
of Privacy Practices, and to make certain that the terms of the notice currently in effect are followed.
• Our Responsibilities: The following categories describe the different ways we use and disclose health information.
For each category of use or disclosure we will explain what we mean and try to give some examples. Not every
use or disclosure in a category will be listed, but the way we are permitted to use and disclose information will fall
into one of these categories. Regardless of the category, we must obtain an authorization for any use or disclosure
of psychotherapy notes except to carry out certain treatment, payment, or healthcare operations as noted below.
Psychotherapy notes means notes recorded in any medium by a health care provider who is a mental health
professional that documented or analyze the contents of the conversation held during a private, group, joint, or
family counseling sessions that are separated from the rest of the medical record. Psychotherapy notes excludes
medication prescription and monitoring , counseling sessions start and stop times, the modalities and frequencies
of the treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional
status, treatment plan, symptoms, prognosis, and progress to date.
• For Treatment: We may use medical information about you to provide you with medical treatment, care, or
services. The originator of psychotherapy notes may use those notes for your treatment. We may disclose
medical/treatment information about you to doctors, therapist, counselors, nurses, certified medical aids,
technicians, students, consultants, contracted staff, or other center personnel who are involved in taking care of
you at our facility. For example, if you are treated for depressions, it may be necessary to know that you have
been diagnosed with substance abuse because untreated substance abuse may impede the recovery from
depression. We may also disclose medical information about you to people outside the center who may be
involves in your medical care, either while you are a client or after your course of treatment is completed.
Examples of this may be physicians, other mental health and/or substance abuse professionals, or personnel from
other agencies who partner with us in providing services that are part of your care. If you would like us to share
information regarding your health/treatment status with your family members, you will be given the opportunity
to sign an authorization permitting us to do so. If you choose not to sign this, information will not be given without
a legal consent for the requesting party to obtain it, unless the appropriate authorization is received from you
prior to the request.
• For Payment: We may use and disclose health information about you so that the treatment and services you
receive at Community Counseling Center may be billed to and payment collected from you, a government payer,
or third party. For example, we may need to give your health plan, Medicaid, or Medicare information about the
services you received at our center so we will be paid for these services. We also may tell Medicaid, Medicare, or
your health plan about a treatment modality you are going to receive to obtain prior authorization for that
treatment. If the services you are receiving are provided under federal or private grant, we may provide the agency
disbursing those funds for that grant with information about the services you have received so the grant funds
may be properly dispersed an applied.
• For Operations: We may use and disclose information about you and the services you receive at our center for
operations. These uses and disclosures are necessary to run the center and make sure that our clients receive
quality care. For example, we may use treatment information to review our care and services and to evaluate the
performance of our staff caring for you. We may use or disclose psychotherapy notes to our own training programs
in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their
skills in group, joint, family, or individual counseling. We may also combine treatment information about many
clients to decide what additional services the center should offer, what services are not needed, and whether
certain new services warranted. We may remove information so others may use it to study mental health care
and substance abuse treatment, and the treatment delivery system, without learning who the specific clients are.
• For Service Alternatives: We may use and disclose medical/treatment information to tell you about or recommend
possible service options or alternatives that may be of interest to you.
• Health Related Benefits and Services: We may use and disclose medical/treatment information to tell you health
related benefits or services that may of interest to you.
• Individuals Involved in Your Care or Payment for Your Care: We may release treatment information about you to
a friend or family member who is involves in your care, but only with your authorization. Nevada State law (NRS
49.209 and NRS 49.247) establishes the “general rule of privilege” by which we are bound.
• As Required by Law: We will disclose medical/treatment information about you when required to do so by federal,
state, or local law.
• To Avert a Serious Threat to Health or Safety: We may use or disclose medical/treatment information about you
when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or
another person. Any disclosure, however, would only be to someone able to help prevent the threat.
• Military Command Authorities: We may use or disclose medical/treatment information about you as required by
military command authorities. We may also release medical/treatment information about foreign military
personnel to the appropriate foreign military authority.
• Workers’ Compensation: We may release medical/treatment information about you for workers’ compensation
or similar programs. These programs provide benefits for work-related injuries or illnesses.
• Public Health Risks: We may disclose medical information about you for public health activities. These activities
generally include the following:
o To prevent or control disease, jury, or disability.
o To report deaths.
o To report reactions to medications or problems with products.
o To notify people of recalls or products they may be using.
o To notify a person who may have been exposed to a disease or may risk for contacting or spreading a
disease or conditions.
o To notify the appropriate government authority if we believe a client has been the victim of abuse, neglect
or domestic violence in any form. We will only make this disclosure if you agree when required or
authorized by law.
• Coroner, Medical Examiners, and Funeral Directors: We may disclose health information to such entities
consistence with applicable law to carry out their duties.
• Research: We may disclose information to researchers when their research has been approved by an institutional
review board that has reviewed the research proposal and established protocols to ensure the privacy of your
treatment information.
3. HEALTH INFORMATION RIGHTS - You have the following rights regarding medical/treatment information we
maintain about you:
• Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make
decision about your treatment. Usually this includes medical billing records, but may not include psychotherapy
notes, as per 45 CFR 164.524. We may deny your request to inspect and copy in certain limited circumstances. In
some instance, you may request that this denial be reviewed. Another licensed health care professional chosen
by the center will review your request and the denial. The person conducting the review will not be the person
who denied your request. We will comply with the reviewer’s decision.
• Right to Amend: If you feel that health information, we have about you is incorrect or incomplete, you may ask us
to amend that information, as per 45 CFR 164.528.
• Right to an Accounting of Disclosures: You have the right to request and accounting of disclosures of your health
information, as per 45 CFR 164.528.
• Right to Request Restrictions: You have the right to request restrictions or limitations on certain uses and
disclosures of your information as provided by 45 CFR 164.522.
• Right to Request Confidential Communications: You have the right to request that we communicate with you
about medical/treatment matters in a certain way or a certain location. For example, you can ask that we only
contact you at work or by mail. To request in writing to the Administrator or the Health information Management
Coordinator. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your
request must specify how or where you wish to be contacted.
• Right to Paper Copy of this Notice: You have the right to a paper copy of this notice, even if you have agreed to
receive this notice electronically. You may ask us to give you a copy of this notice at any time. To obtain a paper
copy of this notice, ask any Community Counseling Center employee.
• Other Uses of Your Health Information: Not covered by this notice or laws that apply to us will be made only with
your written permission. If you provide us permission to use or disclose information about you, you may revoke
that permission in writing at any time. If you revoke permission, we will no longer use or disclose information
about you for the reasons covered by you own written authorization. You understand that we are unable to take
back any disclosures we have already made with your permission, and that we required to retain our record of
the care that we provided to you.
• Changes to this Notice: We reserve the right to change to the contents of this notice. We reserve the right to make
the revised or changed notice effective for medical/treatment information we already have about you as well as
any information we receive in the future. We will post a copy of the current notice in the center.
• Complaints: If you believe your privacy rights have been violated, you may file complaints with the Community
Counseling Center Privacy Point of Contact or with the Secretary of the Department of Health and Human Services.
To file a complaint with this center, contact the Privacy Point of Contact. All Complaints must be submitted in
writing. You may obtain a complaint form from any employee.
You will not be penalized for filing a complaint. This is effective date of this notice is April 14, 2003.
4. BUREAU OF HEALTH REGULATIONS POLICY
CCC does not deny or delay treatment to a prospective client on the grounds of handicap, race, gender, religious
beliefs, sexual orientation, gender identity, national origin, and/or ability to pay for services. No client shall be
given separate treatment, restricted in the employment of any advantage or privilege enjoyed by others under
the program or with any aid, treatment, services, or other benefits which are different, or provided in a different
manner from that provided to others under the program, on the grounds of handicap, race, gender, religious
belief, sexual orientation, gender identity, national origin, and/or ability to pay for services.
5. FEE DETERMINATION POLICY AND FINANCIAL INFORMATION
The following information is protected under the confidentiality regulations of HIPAA and 42 CFR.
• You may be eligible for a determination of fees according to a sliding fee schedule that is contingent upon your
providing verifying information. Such documentation should be provided at the intake session at which your share
of costs is determined. If a client cannot provide proof of income, or if a client is indigent/homeless, we require a
signed, written statement as proof of such. If a client qualifies for the sliding fee scale, then his/her session fees
will be lowered appropriately. If you are not able to pay the full amount of the evaluation fee at this time, you
may make payment arrangements with authorized staff. If you qualify for Medicaid, you are not eligible for the
sliding scale. Sliding scale qualified individuals include but are not limited to mandated clients outside of
Medicaid/insurance session limits, undocumented aliens, and those individuals pending Medicaid. Client fees for
those who are not eligible for the SAPTA sliding scale are based on the current full fees and unit cost.
• To qualify for the Sliding Fee Scale, you MUST bring in proof of income documentation for ALL income you and
any members of your household may receive. Examples of this documentation include W-2 forms, tax returns,
last two check stubs, bank statements, letters of I understand and accept Community Counseling Center’s fee
determination policies. I hereby agree to be financially responsible for all charges incurred regardless of insurance
coverage. In the event my account is referred to a collection service due to lack of payment on my part, I agree
to pay all collection/legal fees that may be added to my account.
• Please read carefully:
o Once the fee has been determined by the above process, refusal to pay may result in discharge from the
program per state of Nevada Division of Mental Health & Developmental Services.
o A twenty-five ($25.00) dollar non-sufficient fund (NSF) fee will be charged for checks initially returned
unpaid by your bank. If the same check is returned unpaid a second time it may be referred to a collection
service for recovery.
o We do not accept out of state checks or check for final payment of your bill.
6. CONSENT TO TREATMENT
As a client of Community Counseling Center, I understand that:
• I am entitled to treatment and rehabilitative care to include referrals to appropriate, psychological and training
services, as part of my treatment plan.
• I have the right to refuse any or all parts of my treatment plan, with the exception of emergency treatment.
• Consent to any or all parts of the treatment plan may be withdrawn at any time.
• I will be informed of the nature, consequences and purpose of the treatment plan, and any alternative plans and
resources available.
• All counseling sessions are confidential, but I understand that my counselor is obligated by law to inform
appropriate parties if I am in danger or if I am causing danger to someone else.
• Admission to this program does not include granting Power of Attorney to the operator or employees of the
program.
• Community Counseling Center is an approved internship site, which utilizes interns to assess, diagnose, and treat
its client under strict supervision. By signing below, I hereby consent and acknowledge that an intern may conduct
my counseling sessions at Community Counseling Center.
• Although I may be assigned a certain number of counseling sessions at the start of my treatment, completing this
number of sessions does not necessarily mean that I have successfully completed my treatment. If I have not met
my treatment goals, additional sessions may be recommended by my counselor.
• As a client of Community Counseling Center, I have read my rights and acknowledge receipt of a copy of Client
Rights.
• I understand that successful treatment is demonstrated by mental and behavioral changes sustained over time. I
will have a regular opportunity to discuss with my primary therapist my progress (or lack of progress) toward
meeting these goals.
• I have been fully informed of the above, understand the process and my responsibilities as a client receiving
treatment, and agree to accept such treatment and to cooperate in its implementation.
7. CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE CLIENT RECORDS - 42 U.S.C. 290ee for federal laws & 42 CFR
Part 2 for federal regulations
The confidentiality of alcohol and drug client records, maintained by this program (Community Counseling Center),
is protected by federal law and regulations. Generally, the program, staff, volunteers, or contractual personnel
may not say to a person outside the program that a client attends the program, or disclose any information
identifying a client as an alcohol or drug abuser.
• Unless:
o The client consents in writing.
o The disclosure is allowed by a court order, or
o The disclosure is made to medical personnel in a medical emergency, or to qualified personnel for
research, audit, or program evaluation.
o The client commits or threatens to commit a crime on program premises, or against program staff.
• Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to
appropriate authorities in accordance with federal regulations.
• Federal law and regulations do not protect information about a crime committed by a client, either on the
premises or against any program staff, or about any threat to commit such a crime.
• Federal law and regulations do not protect information about suspected child abuse or neglect from being
reported under state law to appropriate state or local authorities.
• Federal law and regulations prohibit the re-disclosure of protected information by the disclosure.
8. CLIENT DRESS CODE - serves to provide guidelines for clients’ dress and appearance.
Clients are to be dressed in such a manner that their appearance at the agency contributes to the therapeutic
environment. Exemption from the CCC Basic Dress Code may be permitted for medical or religious reasons with
counselor approval.
• Require the wearing of footwear with soles.
• All clothing must be sufficient to conceal any and all undergarments. No skin will show between bottom of
shirt/blouse and top of pants or skirts at any time. All sleeveless shirts must have straps. Prohibited tops include,
but are not limited to, crop tops, strapless, low-cut clothing, clothing with slits, or tops and outfits that provide
minimum coverage.
• Require that all shorts, skorts, skirts, and jumpers/dresses must be at least at fingertip length.
• All jeans, pants, and shorts must be secured at waist level. Sagging is strictly prohibited. Jeans, pants, and shorts
are not to have rips or tears that expose undergarments and/or are located mid-thigh or higher.
• Slogans or advertising on clothing, jewelry, buttons, and/or accessories which by their controversial,
discriminatory, profane, and/or obscene nature disrupt the therapeutic setting are prohibited.
• Any clothing, jewelry, buttons, and/or accessories that promote illegal or violent conduct, or affiliation with groups
that promote illegal or violent conduct such as, but not limited to, the unlawful use of weapons, drugs, alcohol,
tobacco, or drug paraphernalia, or clothing that contains threats are prohibited.
• Clothing may not, at any time, be used to conceal weapons, drugs, or other related paraphernalia.
* What constitutes a violation of these guidelines may be subject to the discretion of the staff of Community
Counseling Center. CCC reserves the right to request that a client wearing inappropriate attire change his/her
clothing, obtain an appropriate garment from the agency Resource Room, or be asked to leave and make up the
missed appointment later.
9. TELEHEALTH/TELECOUNSELING POLICIES AND ACKNOWLEDGEMENT
• I understand that my counselor and/or administrative staff, has recommended to me that I engage in a
Telecounseling/Telehealth appointment with Community Counseling Center/CCC.
• My counselor or/and administrative staff has explained to me how the telehealth technology will be used to
connect me with a provider. Telehealth appointments may be conducted by videoconferencing, video images, still
(high quality photo) images, or by telephone conference. I understand that this appointment will not be the same
as a direct client/counseling/case management visit due to the fact that I will not be in the same room as my
Community Counseling Center provider.
• I understand there are potential risks to this technology, including interruptions, unauthorized access and
technical difficulties. I understand that my health care provider or I can discontinue the telehealth appointment if
it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can
discontinue the telehealth appointment at any time.
• I understand that my counseling, case management information may be shared with other individuals for
scheduling and billing purposes. Others may also be present during the appointment other than my CCC provider
and specialty health care provider in order to operate the equipment. The above-mentioned people will all
maintain confidentiality of the information obtained. I further understand that I will be informed of their presence
during the consultation and thus will have the right to request the following: (1) omit specific details of my
counseling that are personally sensitive to me; (2) ask non-clinical staff personnel to leave the telehealth
examination room; and/or (3) terminate the telehealth appointment at any time.
• In an emergency situation, I understand that the responsibility of the telehealth specialist or provider may be to
direct me to emergency medical services, such as emergency room. Or the telehealth provider may discuss with
and advise my local provider. The telehealth specialist’s or provider’s responsibility will end upon the termination
of the telehealth connection.
• I understand that billing for the telehealth consultation may occur from 1) the CCC provider and 2) telehealth
provider, and 3) as a facility fee from the site from which I am presented. Billing is at the discretion of the provider.
Billing procedures will be explained to me.
• I
have read this document carefully, and understand the risks and benefits of the telehealth appointment and
have had my questions regarding the procedure explained and I hereby consent to participate in a telehealth
appointment visit under the terms described herein.
1
0. Appointment Reminders and Other Healthcare Communications
As a client in our practice, you may be contacted via telephone, email and/or text messaging by CCC staff for
various reasons as follows:
• To
remind you of an appointment – via phone call and/or approved voicemail message.
• T
o remind you of an appointment – via automated text message or email.
• To
obtain feedback on your experience with our healthcare team via telephone.
• To provide general health information via telephone or email.
• C
CC may also communicate via social media private messages under the following circumstances:
o Th
e private message is either initiated by the client or is the only means of communication with the client.
o N
o confidential information is discussed.
• I
understand that I might receive appointment reminders and other healthcare communications/ information
from Community Counseling Center.
• I
also understand that I might receive text messages, which may incur charges in accordance with my cell phone
data plan, at my cell phone and any number forwarded or transferred to that number or emails to receive
communication as stated above.
Client Acknowledgement(s)
Client Name: Date of Birth:
I certify that I will furnish all insurance cards/paperwork and financial documentation as requested by
Community Counseling Center. I have included these documents:
C
lient Identification (Driver’s License, State ID, Clarity Card, etc.)
Insurance Card(s) (scanned or pictures of front and back)
Documentation of Household Income (Tax Returns, W2 for all household members, check stubs for all household
members, etc.)
Th
e cell phone number/email that I authorize to receive text messages for appointment reminders, feedback, and general
health reminders/information is:
( ) - & @
I acknowledge I have or will be receiving a copy of the following documents: (please initial each item)
CLIENT RIGHTS AND RESPONSIBILITIES
NOTICE OF PRIVACY PRACTICES (HIPAA)
HEALTH INFORMATION RIGHTS
FEE DETERMINATION POLICY AND FINANCIAL INFORMATION
CONSENT TO TREAT
CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE CLIENT RECORDS
CLIENT DRESS CODE
TELEHEALTH/TELECOUNSELING POLICIES AND ACKNOWLEDGEMENT
A copy of a/all consent(s) to release information.
A copy of CCC’s treatment recommendations.
POLI
CY ACKKNOWLEDMENT: (please initial each item)
I acknowledge that I have read and understand this form pertaining to Community Counseling Center’s Important
Policy Information.
I acknowledge that I have read and understand this form pertaining to Community Counseling Center’s Mandated
Program Policy Statement.
I acknowledge that I have read and understand this form pertaining to Community Counseling Center’s Fee
Determination Policy. I hereby agree to be financially responsible for all charges incurred regardless of insurance coverage.
In the event my account is referred to a collection service due to lack of payment on my part, I agree to pay all
collection/legal fees that may be added to my account.
I acknowledge that I understand that Community Counseling Center does not deny or delay treatment to a
prospective client on the grounds of handicap, race, gender, religious beliefs, sexual orientation, gender identity, national
origin, and/or ability to pay for services. No client shall be given separate treatment, restricted in the employment of any
advantage or privilege enjoyed by others under the program or with aid, treatment, services, or other benefits which are
different, or provided in a different manner from that provided to others under the program, on the groups of handicap,
race, gender, religious beliefs, sexual orientation, gender identity, national origin, and/or ability to pay for services.
I understand that I may be asked to submit to random UAs (urinalysis) or breathalyzer testing and that I am
responsible for the cost(s) associated with these tests.
I consent to receive text messages and emails, to receive communications as necessary from Community
Counseling Center.
Client/Guardian Signature:
Date:
Community Counseling Center
Authorization to release information to and collect payment from insurance
Client Name:
Date of Birth: Social Security Number:
Relationship to insured:
Insurance Company (please check all that apply):
Medicare Medicaid only
Medicaid MCO:
Anthem Blue Cross Blue Shield Healthcare Solutions Silver Summit
HPN – TANF Expansion HPN – TANF (HBI) HPN – CHAP/Pregnancy
Other:
Insurance Company Address:
Insurance Company Phone:
Group Policy Name/Number:
Employer:
Insured ID:
Other ID:
Additional/Other Insurance:
I hereby authorize Community Counseling Center to release information to my insurance provider(s) about the
diagnosis and the therapeutic services provided to me (or to the above-named Client if a minor). I also
authorize my insurance provider to release information regarding recipient eligibility and remit payment
directly to Community Counseling Center. I understand that I am responsible for payment of all services
rendered if my insurance and/or other funding source does not pay for my services after a reasonable effort
has been made by Community Counseling Center.
Client/Guardian Name (Printed):
Client/Guardian Signature:
Date:
Information provided pursuant to this release is protected by all applicable confidentiality regulations.
Further release of this information requires specific authorization by the client.
Community Counseling Center - Telecounseling Information
The COVID-19 pandemic has dramatically changed both our personal and professional lives. With social
distancing in effect and the frustration of being not able to go out and socialize, web or telephone-based
treatment has become more common. Zoom is a web-based video conferencing tool that for computers,
tablets, and smartphones that to meet online, with or without video. You can now have visual and audio contact
with your therapist or case manager from the safety and comfort of your home. Please review the following
information for your upcoming telecounseling or case management session.
• Please read and sign all forms sent to you by CCC staff. In these forms you will find Community
Counseling Center’s client consents, policies, and procedures, as well as HIPPA and Federal Privacy
regulations.
• Your appointments (individual and group sessions):
o Before your group or individual session begins, please move to in a private and confidential
setting in which you are comfortable. Turn off or remove televisions and other distractions.
o If your session is telephone only (not via Zoom), then wait for your counselor or case manager to
call you at your appointment time.
o If utilizing Zoom, click on the link provided in your email at the appropriate time. Your internet
browser or app will open and take you to a waiting room that was enabled before your session
to ensure confidentiality. Your counselor or case manager will then confirm your appointment
and let you into the session.
o If you are using Zoom for the first time, please click the email link to begin your session at least
five to ten minutes early to allow installation and your setting to be configured. If using Zoom for
a group session, any personal information that would be displayed, such as a phone number or
email, will be hidden by your counselor or case manager.
o If you are attending a group session, please follow all group rules as communicated by your
counselor or case manager. These rules are also included in your client paperwork.
• Appointment attendance:
o If your session is telephone only and do not answer when your assigned counselor or case
manager call, you will be called again within 10 minutes. If you do not answer after two phone
calls, your session will be considered a “No Show”, and your appointment time may be given to
another client.
o If your session is via Zoom and you are not connected by the start of the appointment time, your
counselor or case manager will wait up to 10 minutes for you to connect. After this time, your
session will be considered a “No Show”, and your appointment time may be given to another
client. If you have trouble connecting, please call 702-369-8700 and inform staff. Your counselor
or case manager may call you to conduct your session via telephone only, or he/she may
reschedule your session depending on availability.
If you have any questions regarding telecounseling or case management, or would like further information
regarding CCC services and programs, please call 702-369-8700 to speak to your assigned counselor or case
manager, or email ccc@cccofsn.org and your email will be forwarded to the appropriate staff.
Thank you for trusting CCC during this difficult time. Stay safe.
Copyright © 2013 American Psychiatric Association. All Rights Reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult
Name: ___________________________ Date:________
If this questionnaire is completed by an informant, what is your relationship with the individual? ___________________ In a typical
week, approximately how much time do you spend with the individual? ____________________ hours/week
Instructions: The questions below ask about things that might have bothered you. For each question, check the box that best describes
how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.
During the past TWO (2) WEEKS, how much (or how often) have you been
bothered by the following problems?
Slight
Rare, ess
than a day
or two
Mild
Several
days
Moderate
More than
half the
days
Severe
Nearly
every
day
Highest
Domain
Score
(clinician)
I.
1. Little interest or pleasure in doing things?
1
2
3
4
2. Feeling down, depressed, or hopeless?
1
2
3
4
II.
3. Feeling more irritated, grouchy, or angry than usual?
1
2
3
4
III.
4. Sleeping less than usual, but still have a lot of energy?
1
2
3
4
5. Starting lots more projects than usual or doing more risky things than
usual?
1
2
3
4
IV.
6. Feeling nervous, anxious, frightened, worried, or on edge?
1
2
3
4
7. Feeling panic or being frightened?
1
2
3
4
8. Avoiding situations that make you anxious?
1
2
3
4
V.
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
1
2
3
4
10. Feeling that your illnesses are not being taken seriously enough?
1
2
3
4
VI.
11. Thoughts of actually hurting yourself?
1
2
3
4
VII.
12. Hearing things other people couldn’t hear, such as voices even when no
one was around?
1
2
3
4
13. Feeling that someone could hear your thoughts, or that you could hear
what another person was thinking?
1
2
3
4
VIII.
14. Problems with sleep that affected your sleep quality over all?
1
2
3
4
IX.
15. Problems with memory (e.g., learning new information) or with location
(e.g., finding your way home)?
1
2
3
4
X.
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
1
2
3
4
17. Feeling driven to perform certain behaviors or mental acts over and over
again?
1
2
3
4
XI.
18. Feeling detached or distant from yourself, your body, your physical
surroundings, or your memories?
1
2
3
4
XII.
19. Not knowing who you really are or what you want out of life?
1
2
3
4
20. Not feeling close to other people or enjoying your relationships with them?
1
2
3
4
XIII.
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
1
2
3
4
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
1
2
3
4
23. Using any of the following medicines ON YOUR OWN, that is, without a
doctor’s prescription, in greater amounts or longer than prescribed [e.g.,
painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or
tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine
or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin,
inhalants or solvents (like glue), or methamphetamine (like speed)]?
1
2
3
4
Scoring:
0 1 2 3 4
CM Needs Assessment Lite
Client Name: Date:
Household Income Information (Exhibit E)
Items needed (copies):
Photo ID of Head of Household
Proof of monthly household income to include all income sources for each member of the household (paycheck
stubs, income tax statement).
Other income documentation (child support, alimony, welfare, etc.)
Any letter from an agency that verifies income status is acceptable (i.e. a letter from public housing, food
stamps, welfare, check stubs, etc.)
Household Members:
Female Head of Household? yes no Is the Head of Household single? yes no
Household size (integer): Is Head of Household disabled? yes no
Household yearly income? Number of adults in household:
Number of children in household: Anyone in household pregnant? yes no
List all additional members (other than the client) of the household including minor children. If more than 5 additional
members live in the household, please check the additional members box and list their information in the comments box
1. First Name: Last Name:
DOB: Gender: Male Female TG - M to F TG - F to M Undisclosed
Head of Household yes no Monthly Income:
2. First Name: Last Name:
DOB: Gender: Male Female TG - M to F TG - F to M Undisclosed
Head of Household yes no Monthly Income:
3. First Name: Last Name:
DOB: Gender: Male Female TG - M to F TG - F to M Undisclosed
Head of Household yes no Monthly Income:
4. First Name: Last Name:
DOB: Gender: Male Female TG - M to F TG - F to M Undisclosed
Head of Household yes no Monthly Income:
5. First Name: Last Name:
DOB: Gender: Male Female TG - M to F TG - F to M Undisclosed
Head of Household yes no Monthly Income:
CM Needs Assessment Lite
Please answer each of the following questions, for each YES, please provide documentation.
Does any member of your household live in public housing or receive Section 8 assistance? yes no
Does any member of your household work full-time, part-time, or seasonally? yes no
Does any member of your household expect to work for any period during next year? yes no
Does any member of your household work for someone who pays in cash? yes no
Does any member of your household receive or expect to receive unemployment benefits? yes no
Does any member of your household receive or expect to receive child support? yes no
Does any member of your household receive or expect to receive alimony? yes no
Does any member of your household receive or expect to receive public assistance or welfare? yes no
Does any member of your household receive or expect to receive Social Security or retirement benefits? yes no
Are you enrolled in Medicaid? yes no If no, a Case Manager will schedule a time for your Medicaid enrollment.
Do you receive Case Management services from another agency: yes no
If yes, what agency?
Immediate Needs (Do you or your family members need help with any urgent or pressing problems right now other than
counseling/therapy? This can include help with employment/resumes, applying for social services such as food stamps
or disability, transportation to/from your counseling sessions, housing needs, etc.):
Client Signature:
Date:
Parent/Guardian Signature:
Date:
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Completed 6 May 2021

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