NEW PATIENT INTAKE FORM

CONSENT FOR ALCOHOL OR DRUG ASSESSMENT AND TREATMENT

I understand that while I am an active patient at KAV Health Group I am eligible to receive a range of services. The type and extent of services that I will receive will be determined following an initial Clinical Assessment and discussed with me. The goal of the Clinical Assessment process is to determine the best course of treatment for me. Typically, treatment is provided based on the ASAM Level of Care.

1. Consent to Evaluate/Treat: I voluntarily consent that I will participate in an alcohol or drug assessment and/or treatment by staff from KAV Health Group. I understand that.following the assessment and/or treatment, complete and accurate information will be provided concerning each of the following areas:
   1. The benefits of the proposed treatment
   2. Alternative treatment modes and services
   3. The manner in which treatment will be administered
   4. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable)
   5. Probable consequences of not receiving treatment

   Treatment will be conducted within the boundaries of Ohio substance abuse treatment laws. I understand that a range of mental health professionals, some of whom are in training, provides KAV Health Group services. All professionals-in-training are supervised by licensed staff.

2. Benefits and Risks to Assessment/Treatment: Assessment and treatment may be administered with psychological interviews, psychological assessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to me, as well as the referring professional, to understand the nature and cause of any difficulties affecting my daily functioning so that appropriate recommendations and treatments may be offered. Uses of this assessment include diagnosis, assessment of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations. I understand that while ,psychotherapy and/or medication may provide significant benefits, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings or may lead to the recall of troubling memories. I realize that sometimes medications may have unwanted side effects.
3. Research: As part of ongoing client satisfaction surveys and future research some information from your file may be submitted to third parties or utilized by KAV HealthGroup. Your identifying information will not be shared; however, general information (age, race, and sex) may be shared.
4. Charges: Fees are based on the length or type of the assessment or treatment, which are determined by the nature of the service. i will be responsible for any charges not covered by insurance, including co-payments and deductibles. Fees are available to me upon request.
5. Confidentiality: Information from my assessment and/or treatment is contained in a confidential medical record at KAV Health Group. A photograph will be taken and stored in the electronic health record as a primary form of my identification. The purpose of this photo is to be in compliance with KAV Health Group policy and procedures of using two forms of identification to recognize each client.
6. Right to Withdraw Consent: I have the right to withdraw my consent for assessment and/or treatment at any time by providing a written request to the treating clinician.
7. General Laboratory Testing and Reporting: Laboratory testing, including but not limited to blood work, may be requested. This testing may be to identify a diagnosis of HIV, Hepatitis B or C, or other Bloodborne disease. Positive results from this lab work must be reported to the appropriate authorities. I authorize KAV Health Group to disclose any reportable infectious disease and information regarding that infectious disease to my local and state health department for purposes of coordinating care. Only the minimum amount of protected health information needed to accomplish the intended purpose of the use is permitted for these disclosures. I understand that my alcohol and/or drug abuse treatment records are protected under federal regulations 42
   1. F.R Part 2 – Confidentiality of Alcohol and Drug Abuse Patient Records and cannot be disclosed without my written consent. I may revoke this consent in writing at any time. I understand that the revocation will not be effective retroactively for information disclosures that have already occurred. If not previously revoked, this consent will remain valid 90 days after discharge.
   2. Toxicology Testing: I understand that upon admission and throughout my course of treatment, I will be required to submit to a variety of toxicology tests to include urine drug testing, alcohol testing, pregnancy testing (if applicable), and blood/lab work testing. The treatment team and provider will determine the frequency of these tests. I give my consent to undergo all tests described above as they apply to me. I further give my consent to allow KAV Health Group to send my urine specimen to the laboratory for analysis.
8. Expiration of Consent: This consent to treat will expire 12 months from the date of signature, unless otherwise specified.
9. Informed Consent for Medication Assisted Treatment: In accordance with evidence-based practices, KAV Health Group assessment and evaluation and at the recommendation of a physician may prescribe various medications to assist with patients in recovery. These medication are used in conjunction with group counseling, individual counseling, and family counseling, Any medication I receive may have an adverse reaction and/or possible side effects.

The goal of medication assisted treatment is to stabilize functioning. I realize that some patients’ treatment may continue for relatively long periods of time, but that periodic consideration shall be given concerning my complete withdrawal from the use of all drugs.

TREATMENT WITH BUPRENORPHINE (IF APPLICABLE):

Buprenorphine is an FDA approved medication for the treatment of opioid addiction. Buprenorphine can be used for detoxification or for maintenance therapy. Maintenance therapy can continue as long as medically necessary. There are other treatments for opioid addiction, including methadone, naloxone, and some treatments without medications. The appropriate treatment plan for you will be determined by your primary counselor and a physician.

Use of buprenorphine will maintain your physical dependence. If you discontinue it suddenly, you will likely experience withdrawal. If you are not already dependent, you should not take buprenorphine as it could eventually cause physical dependence. The medication you will be taking will likely contain both buprenorphine and an opiate blocker (naloxone). If the medication is abused by snorting or injection, the naloxone will cause severe withdrawal but when taken as directed, the naloxone has no effect.

If you are dependent on opioids you should be in as much withdrawal as possible when you take the first dose of buprenorphine/naloxone. If you are not in withdrawal, buprenorphine/naloxone can cause severe opioid withdrawal. We recommend that you arrange not to drive after your first dose, because some patients may experience drowsiness during the early phases of treatment. It may take several days to feel completely comfortable with the transition to buprenorphine/naloxone.

Combining buprenorphine with alcohol or other sedating medications is dangerous. The combination of buprenorphine with benzodiazepines (such as Valium®, Librium®, Ativan®, Xanax®, Klonopin®, etc.) has resulted in deaths. Although sublingual buprenorphine has not been shown to be liver-damaging, your doctor will monitor your liver tests while you are taking buprenorphine. (This is a blood test.) Attempts to override the buprenorphine by taking more opioids could result in an opioid overdose. You should not take any other medication without discussing it with the physician first.

I understand that buprenorphine products and other medication assisted treatment medications may interact with other prescription medications, vitamins and nutritional supplements. Potential interactions include increasing or decreasing the level of buprenorphine products in my body or, in extremely rare instances, possibly causing an abnormal heart rhythm that has the potential to be lethal. I agree that it is my responsibility to provide documentation of all medication, vitamins and nutritional supplements I am taking on at least a monthly basis.

I understand that I may withdraw from this treatment and discontinue the use of the medication at any time, and I shall be afforded medical withdrawal under medical supervision. The medically supervised withdrawal could be either a short-term withdrawal or long-term withdrawal. This will be at the discretion of the Medical Director/Provider. I understand that once I complete a medically supervised withdrawal, I may be offered an aftercare program which will include counseling only.

I have read and understand these details about medication assisted treatment, including risks and benefits. I understand there are alternatives and wish to be treated with buprenorphine if that is the medication that the physician deems medically appropriate.

I agree that I shall inform any doctor who may treat me for any medical problem that I am enrolled in a substance use disorder treatment program, since the use of other medications in conjunction with medication assisted treatment prescribed by the treatment program may cause me harm. In addition, I agree that I am not currently enrolled in another Office Based Opioid Treatment (OBOT) at this time.

I understand State and Federal law prohibits dual enrollment in opiate treatment programs. I therefore give my consent to allow KAV Health Group to disclose my enrollment status, via fax or verbal confirmation, to all opiate treatment programs in accordance with state and federal law guidelines. I further give my consent to allow KAV Health Group to disclose my enrollment status, via fax, electronic transfer or verbal confirmation, to a statewide Central Registry in accordance with State and Federal law as well as any other OBOT within a 150-mile radius.

Patient Financial Responsibility Agreement

Dear Patient,

Welcome to KAV Health Group. We appreciate the opportunity to be of service to you. Our office is dedicated to excellence in patient care. To maintain our high standards, we believe that it is important to communicate our policies to you. Please take a moment to read and become familiar with these policies. Should you have any questions, the office staff is happy to help answer them. By presenting these policies in advance, we can avoid any surprises or misunderstandings. We appreciate your time and your understanding.

• Payment Responsibility: I have discussed responsibility for payment for treatment and I assume financial responsibility for myself and/or my family members. I understand that payment or co-payment is due at the time services are rendered unless special arrangements have been made. It is my responsibility to confirm coverage that is provided by my insurance company or other provider. I understand that if I am a Kentucky or Indiana resident that no benefits provided by the State of Ohio will be provided to me.
• Charges for Additional Services: I understand that charges will be added to my account for other professional services rendered. These charges will be in increments of 15 minutes or by encounter; and KAV Health Group will always discuss additional charges with me. Other professional services include extended contact via email, consulting with other professionals (with my permission), preparation of records or treatment summaries, and the time spent performing any other service I may request.
• Appointments & Cancellations: I understand that I am required to provide at least 24 hours advance notice if unable to keep any schedule appointment because the scheduled time slot has been reserved exclusively for me and/or my family members. In the event that I do not provide 24 hours advance notice, I am financially responsible for the reserved appointment. KAV Health Group may make exceptions and waive the fee, at its discretion, for emergency or unusual circumstances. I understand that insurance companies do not provide reimbursement for canceled sessions. Repeated missed appointments may result in termination of therapy. There may be a time when my therapist or physician may need to cancel my appointment for an emergency; KAV Health Group will make every effort to reschedule me/my family in an appropriate time frame. This will be at no charge to me.
• Returned Check Fee: I understand that a fee of $35.00 will be added to my account for any check returned by my financial institution regardless of reason. Should a check be returned, I will not be permitted to write a check again for a period of 6 months.
• Self-Pay: I understand that if requested by clinical and/or medical to complete a counseling session I will be required to pay a fee of $25 up to $100 per session. This fee must be paid prior to scheduling the counseling session.
• Delinquent Accounts: I understand that my account may be turned over for collection and I will be responsible for all costs of collection monies owed, including court costs, collection and attorney fees. I further understand that if I fail to make any of the payments for which I am responsible in a timely manner, I may be charged a 1.5% service charge monthly on the remaining balance.