Initial Intake Form

Instructions: The Client Intake Form is to be completed prior to the initial assessment. Completion of this form is required. Please check the boxes, or fill in the blanks below for each question.

Step 1 of 10

BEFORE YOU BEGIN*
I understand I must have valid ID before the day of my assessment or I will be rescheduled.
Completion of this form is required before assessment. Please note Set Free Alaska does not serve sex offenders at this time.*
I Understand the Statement Above

Consent
Consent*
I understand that the information in this correspondence may contain information relating to my substance use diagnosis and/or treatment, mental health diagnosis and/or treatment, and/or Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS)
Consent*
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the agencies identified above may not condition my treatment on whether I sign a consent form, but that in certain circumstances I may be denied treatment if I do not sign a consent form.
Consent*
I understand and consent to the use of all electronic communication, text messaging and email and that they all have potential security risks.
Consent*
I Consent For Set Free Alaska To Verify My Health Insurance Coverage.
Signature of Client*
Client Name*
First Last
Date*
MM slash DD slash YYYY
Signature of Parent, Guardian or Representative
Relationship to Client
Date
MM slash DD slash YYYY

DISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION
I UNDERSTAND THAT MY ALCOHOL AND/OR DRUG TREATMENT RECORDS ARE PROTECTED UNDER THE FEDERAL REGULATIONS GOVERNING CONFIDENTIALITY AND DRUG ABUSE PATIENT RECORDS, 42 C.F.R. PART 2, AND THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (“HIPAA”), 45 C.F.R. PTS 160 AND 164, AND CANNOT BE DISCLOSED WITHOUT MY WRITTEN CONSENT UNLESS OTHERWISE PROVIDED FOR BY THE REGULATIONS.

I UNDERSTAND THAT I MAY BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR THE PURPOSES OF TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS, IF ALLOWED BY STATE LAW. I WILL NOT BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR OTHER PURPOSES.

I HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THIS REQUEST/AUTHORIZATION TO RELEASE AND/OR OBTAIN RECORDS AND INFORMATION, INCLUDING THE NATURE OF THE RECORDS, THEIR CONTENTS, AND THE CONSEQUENCES AND IMPLICATIONS OF THEIR RELEASE. I UNDERSTAND THAT ONCE MY INFORMATION IS RELEASED, SFA CANNOT PREVENT THE REDISCLOSURE OF THAT INFORMATION, HOWEVER DOES PROVIDE A STATEMENT OF PROHIBITION AGAINST REDISCLOSURE OF PROTECTED HEALTH INFORMATION WITH DISCLOSURES MADE.

I UNDERSTAND THAT I MAY REVOKE A CONSENT IN WRITING AT ANY TIME, EXCEPT TO THE EXTENT THAT ACTION BASED ON THIS CONSENT HAS ALREADY BEEN TAKEN. SEE RECEPTION FOR INSTRUCTIONS TO REVOKE A CONSENT. IF TREATMENT IS MANDATED AS PART OF PROBATION REQUIREMENTS, A CONSENT MAY NOT BE REVOKED UNTIL CONDITIONS OF PROBATION ARE MET OR PROBATION ENDS.

I HAVE A RIGHT TO RECEIVE A COPY OF THIS SIGNED AUTHORIZATION. I ALSO UNDERSTAND THAT UPON MY WRITTEN REQUEST, SFA MUST PROVIDE A RECORD OF DISCLOSURES MADE FOR LEGAL, ADMINISTRATIVE OR QUALITY ASSURANCE PURPOSES.

NOTICE
PROHIBITING REDISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION

This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (see § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.
Signature of Client, Parent and or Legal Guardian*
Name*
First Last
Date*
MM slash DD slash YYYY

Client Financial Responsibility Agreement
Thank you for choosing Set Free Alaska, Inc. (hereafter referred to as “SFA”) as your treatment provider. We are committed to providing you with quality services. SFA must obtain a valid copy of your identification, current Insurance information and proof of income when applicable.
Insured (Including Medicaid): All services are provided to you with the understanding that you are responsible for the cost regardless of your insurance coverage. If you would like to know the cost of a service, please inquire prior to treatment. Please be aware that not all services are a covered benefit with different insurance companies. You are responsible for knowing what services are or are not covered.
**Important Notice Regarding Medicaid.
** Please be aware that, at this time Medicaid will only pay for one assessment every six months. The assessment must have a diagnosis or level of care for Medicaid to pay for it. If you don’t have a diagnosis or level of care you will be billed for an assessment at the sliding scale fee. **
Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract. It is your responsibility to notify this office immediately if your insurance coverage changes. It is your responsibility to understand your coverage and benefits, including pre-certifications, referral and authorization requirements, and to be sure all insurance information is current.
When possible, we will bill your primary insurance company (including Medicaid) as a courtesy, but you are still ultimately responsible for payment of all services you receive. If your insurance company does not respond within 60 days, we will follow up with an inquiry on your behalf. If, however, your insurance does not respond within 60 days of claim submission, an invoice will be sent to you. You should call your insurance to question why the claim is not paid. Our office will assist you only after you have contacted your insurance
Insured/Non-Insured Payments: We accept cash, check, debit card, and credit cards for MasterCard and Visa.
Insured: Unless a payment plan has been agreed upon prior to the date of service, we will collect your deductible, co- pay, and payment for any uncovered services as well as the client’s portion as determined by insurance at the time of service.
Non-Insured/Under-Insured: If you do not have medical insurance the following applies: Unless a prior financial agreement plan has been signed and payments are current, you will be responsible for a minimum payment at the time of service for the service to be received that day, as well as any previous outstanding balance. We offer a 20% discount for payment in full at time of service.
Sliding Scale: I understand that to be eligible for the sliding fee scale I must provide current proof of income. (Most resent paystub or tax return). I also understand that I must notify Set Free Alaska of any changes or increases that cause me to be no longer eligible for sliding scale.
No-Show Fee: There is a $25.00 fee for missed appointments not cancelled within 24 hours of the scheduled appointment time. These charges are your responsibility and cannot be billed to insurance or Medicaid. This fee maybe waived situationally.
Collection Fee: There is a $25.00 fee for collecting UA samples using an instant-read cup. Use of Instant Read cups are at the discretion of the counselor providing the service.
ASAP Clients: In the event that there is an outstanding balance after sessions are complete, SFA will report to ASAP that client has attended all recommended sessions; however, is not treatment complete due to an outstanding balance.
**We do understand that temporary financial problems may affect timely payment. We encourage you to communicate any such problems so that we can assist you. Please call (907) 746-4732 for account management. **
Release of Information: I assign benefits of my medical insurance contract or Medicaid to SFA and authorize payment directly to SFA. I authorize SFA to release medical information to payers as required for payment of claims for medical services.
Delinquent Accounts: Any unpaid charges over 90 days old will be considered for an outside collection agency. The Collection agency will receive client identifying, contact and financial information. You are responsible for any collection, legal, or court fees incurred in the collections process.
Your clear understanding of our Financial Policy is important to our relationship. Please ask if you have any questions about our fees, Financial Policy, or your financial responsibility. We will discuss our professional fees at any time.
Consent*
I have read and understand the payment policy and agree to abide by its guidelines:
Client Name*
First Last
Client / Guardian Signature*
Date*
MM slash DD slash YYYY

Informed Consent to Treat
I acknowledge that I have received, read (or have had read to me), and understand the information provided to me about the substance abuse treatment I am considering. I have had all my questions answered fully.
• Counseling and therapy are beneficial, but as with any treatment, there are inherent risks. Assessment and subsequent counseling will involve discussion about personal issues and may bring to the surface uncomfortable emotions for any or all the individuals involved. The goal of the counselor is to follow the path of truth, however uncomfortable or painful that may be at times. With substance abuse counseling there are frequently specific recommendations indicated that could involve significant lifestyle changes that the client may not want or agree with; this may be construed as a “risk” associated with treatment. However, the benefits of assessment and counseling can far outweigh the risks. Some of the benefits include improved personal and family relationships, reduced feelings of emotional distress, improved personal performance, reduction of health and safety dangers, and specific problem solving. We cannot guarantee these benefits, of course. It is our desire to work with you to attain your personal goals, which may include obtaining the right help for a client who may be resistant to the treatment process. Set Free Alaska utilizes various evidenced based approaches. As part of the treatment plan the client may participate in any number of these recovery-oriented services: Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET), Dialectical Behavioral Therapy (DBT), Reality and Solution-Based Therapy, Moral Recognition Therapy (MRT), and Eye Movement and Desensitization and Reprocessing (EMDR).
• Counselors and other direct service providers have varying levels of education and certification within their respective fields. Each provider works within their educational and experiential scope of practice. Counselors and other direct service providers will provide credentials upon request.
• I consent to the use of technology to complete my substance abuse or integrated assessment. I understand that this may be completed from home or one of the SFA Out-patient locations.
• I consent to the use of Tele-counseling. Support and insightful discussion will be done via telephone/personal cellular device at a designated time agreed upon by client and provider. I agree to identify my physical location to my provider at the start of each session. • I consent to Video conferencing on the web. Counseling can continue for clients through the internet videoconferencing programs that are secure and HIPAA and 42 CFR Part 2 compliant such as, but not limited to Zoom, Skype for Business, Microsoft Teams, or other similar programs. My provider may also use webinar functionality of Microsoft online portal that will allow providers to post notes, handouts or homework.
• I consent that while attending individual/group sessions online or using a personal cellular device, family members, co-workers and friends will not be present. My participation will be conducted in a private non-public secure area free from distraction. It is highly recommended to utilize headphones during sessions. I understand that I cannot drive while participating in tele-counseling sessions.
• I consent that I will only communicate through a computer/personal cellular device that I know is safe, i.e. wherein confidentiality can be ensured (Be sure to fully exit all online counseling sessions). I further consent, that if we are unable to connect or are disconnected during a session due to a technological breakdown, I will try to reconnect within 10 minutes. If reconnection is not possible, I will call to schedule a new session time.
• Electronic Confidentiality including Audio/Visual, Chat, Phone communication. I consent to transmit therapeutic chat exchanges using encrypted means such as Zoom, SKYPE or Microsoft Teams and understand that use of cell phones, text messages are not confidential. I agree to keep computer files referencing our communication using secure and encrypted measures.
• I understand that non-compliance will result in being dropped from the session or prevented from further participation in telehealth.
• I do hereby seek and consent to take part in the treatment at Set Free Alaska. I understand that developing a treatment plan with my counselor and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.
• I understand that no promises have been made to me as to the results of treatment or of any procedures provided by the therapist/counselor. • I am aware that I may stop my treatment at Set Free Alaska at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)
• I know that I must call to cancel an appointment at least 24 hours (1 day) before the time of the appointment. If I do not cancel and do not show up, I will be personally charged for that appointment even if I have insurance. I consent to the Set Free Alaska no-show policy and understand that if I do not give 24-hour notice or if I am more than 15 minutes late for any individual session, I will be charged $25 no show fee. Furthermore, I understand that if I have continual problems with showing up to my appointments I may be dismissed from the program.
• I agree that I am responsible for the charges for services provided by Set Free Alaska to me (or this client), although other people or insurance companies may make payments on my (or this client’s) account. I agree to pay for the services provided to me (or this client) up until the time the relationship has ended.
• I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive.
• I understand that Set Free Alaska utilizes a clinical treatment team, for ongoing clinical input and decision making.
• I understand that Set Free Alaska uses interns during the course of treatment. These interns may provide various services during the course of treatment under supervision from a trained therapist/counselor as indicated in Set Free Alaska’s policies and procedures.
• I understand that licensure candidates may be under clinical supervision with an entity external to SFA. In these instances, it is understood that all client information will be de-identified in compliance with CFR 42 part 2 and HIPPA regulations.
• I understand that SFA requires an intake physical exam with a focus on substance abuse and clearance for treatment. This allows SFA to get a baseline of medical issues when entering treatment, make referrals to outside medical care if needed, and begin UA testing. Any recommended medical treatment(s) will be thoroughly explained, discussed and agreed to at the time of the exam. Some limited medical issues may also be addressed, including bridge prescriptions if clinically appropriate. Intake medical exam/evaluation for outpatient services will be scheduled using the timelines listed below based on the ASAM 4th edition level of care:
• Level 2.5 within 7 days of intake • Level 2.1 within 14 days of intake Level 1.0 within 30 days of intake
• I understand that the agency does not use seclusion or restraint as part of their nonviolence prevention program.
• I understand that the confidentiality of all counseling interactions is protected by law. Anything you tell your therapist/counselor is considered privileged information and will be held in confidence. Information will not be released about you to others unless you give permission to do so in writing, by signing a release of information form. There are times in which laws and professional codes of ethics require Set Free Alaska staff to break confidentiality such instances include: Medical emergencies
The existence of a threat of danger to self or others
• Reasonable suspicion of current child abuse, abandonment or neglect, dependent adult or elder abuse
A court order or where otherwise legally required
• Third party billing claims requirements
• Receipt of a properly executed consent form
• And where otherwise legally required
• I understand cell phones that have the ability to record are allowed on the premises, but recording is NOT ALLOWED. Staff reserve the right to restrict phone use in group sessions at their discretion. Furthermore, I understand that cell phones are not allowed in residential treatment.
• I understand that all Set Free facilities have 24-hour surveillance that is recorded. Recordings may be viewed by the proper authorities when/if those recordings are required to substantiate any allegations or concerns.
• I understand that smoking, vaping or chewing tobacco is not allowed in the facility and agree to smoke, vape or chew only in the designated smoking areas outside.
I agree to not carry or conceal any weapons within the Set Free Alaska facility.
• I agree to abstain from the use of alcohol and other drugs while participating in the program.
• I understand that I will not prop doors open in order to gain access to the facility. I understand that all outside visitors will be checked in at the front office and must sign an oath of confidentiality.
• I understand that I am not allowed to enter restricted areas of the facility without staff permission or staff escort.
• I understand that Set Free Alaska utilizes websites for such purposes as reviewing legal history.
• I agree to notify my therapist/counselor immediately if I am on or receive any narcotic or other addictive prescription.
• I will not sexually, physically, or verbally assault, threaten, or abuse any agency staff or any other program participant.
• I agree not to possess or sell any alcohol or other mood-altering substance on the premises, or in the parking lot.
• I understand that Set Free Alaska does not administer, maintain, or control my prescription medication in any manner.
• I understand that I will participate in emergency preparedness drills as a part of the agency’s health and safety program.
• I understand that in the event of an emergency, the Set Free Alaska staff will direct me in the necessary actions to be taken.
• I agree to submit to recognized drug screens conducted either at random or upon request by the program staff. I understand that if these tests indicate the presence of alcohol or drugs for which no acceptable reason can be offered, I may be discharged from the program. I also understand that the results of these drug screens may be shared with other agencies or individuals as required by law and allowed by any consent forms I have on file.
• I understand that I may be asked to go to a local laboratory at my own expense for the purpose of conducting drug screening and that a refusal to either submit to a test at the Set Free facility, or my refusal to get a drug screen conducted at a laboratory within a specified amount of time will be considered a failed test.
• I understand that Set Free Alaska uses Millennium Health Lab, which will be billed directly to our clients. The private insurance and Medicaid information will be provided to Millennium Health for the purpose of billing. If you are self-pay you will receive a separate bill from Millennium Health. I understand if my therapist/counselor chooses to use an instant read cup I will be assessed a $12.00 charge.
• Two weeks prior to discharge it is my responsibility to schedule a final financial appointment with the Office Manager.
• Set Free Alaska reserves the right to refuse or reschedule an assessment appointment if there is clinical justification not to proceed.
• I agree to contact 911 or go to the nearest emergency room if I am experiencing a crisis situation.
Name of Client*
First Last
Signature of Client*
Date*
MM slash DD slash YYYY
Name of Parent, Guardian or Representative
First Last
Relationship to Client
Date
MM slash DD slash YYYY
Are You Human? Answer This: 2+1=?*
Consent
I agree to the privacy policy.
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Set Free Alaska

Mat-Su Office 907-373-4732

Homer Office 907-416--7569

Initial Intake Form

Step 1 of 10

Client Profile

Demographics

In case of emergency Set Free Alaska Staff has my permission to notify any of the following persons:

Consent

DISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION

NOTICE

Adverse Childhood Experience (ACE) Questionnaire

Client Financial Responsibility Agreement

Referring Agency Form

Informed Consent to Treat

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