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Adult Mental Health Intake Packet - eSignature

Minnesota CarePartner
393 N Dunlap St. #300 St. Paul, MN 55104
P: 612-289-5656 F: 651-925-0278

Minnesota CarePartner Mental Health Bill of Rights

Client Name:

Client Date of Birth:

Person Signing this form is:

Name of Person Signing this Form:

As a Minnesota CarePartner client, you have a right to:

Receive respectful treatment
Refuse treatment or a particular intervention strategy
Ask questions at any time
Know-how available the counselor is to see you or what the waiting period is
Have full information about fees, method of payment, and insurance reimbursement
Have full information regarding the counselor's qualifications to practice, including licensure or registration, training, and experience
Have full information regarding the counselor's areas of specialization and limitations
Have full information about the counselor's therapeutic orientation and any technique which is routinely used
Have full information regarding your diagnosis if your counselor uses one
Choose a counselor with whom you feel you can work
Experience a safe setting, free from physical, sexual, or emotional abuse
Agree to a written contract of counseling goals and treatment plan
Request that the therapist evaluate the progress of counseling
The right to be allowed access to records and written information from records in accordance with the State of Minnesota Statutes, section 144.335
Require the therapist to send a report regarding your therapy with your written authorization
Confidentiality regarding records and transactions, unless you have signed and authorized, in writing, a release of records, or as otherwise required by law
Information regarding other services that may be available in the community and the freedom to change the provider of service
Coordinated transfer when there has been a change in provider of services
To assert the client's rights without retaliation
Complaints can be made to:
- Minnesota Board of Social Work 612-617-2100
- Office of Ombudsman (BHP referrals), 612-296-0382 or 800-657-5391
- United States Department of Health and Human Services, 877-696-6775

As a recipient of services from a Licensed Marriage and Family Therapist, you have a right:

to expect that a therapist has met the minimal qualifications of education, training, and experience required by state law;
to examine public records maintained by the Board of Marriage and Family Therapy that contain the credentials of a therapist;
to report complaints to the Board of Marriage and Family Therapy;
to be informed of the cost of professional services before receiving the services;
to privacy as defined and limited by rule and law;
to be free from being the object of unlawful discrimination while receiving services;
to have access to their records as provided in Minnesota Statutes, sections 144.291 to144.298, except as otherwise provided by law or prior written agreement;
and to be free from exploitation for the benefit or advantage of a therapist.

As a recipient of services from a licensee of the Minnesota Board of Behavioral Health and Therapy, you have a right to:

expect that the provider meets the minimum qualifications of training and experience required by state law;
examine public records maintained by the Board of Behavioral Health and Therapy that contain the credentials of the provider;
report complaints to the Board of Behavioral Health and Therapy;
be informed of the cost of professional services before receiving the services;
privacy as defined and limited by law and rule;
be free from being the object of unlawful discrimination while receiving counseling services;
have access to their records as provided in sections 144.92 and 148F.135, subdivision 1, except as otherwise provided by law;
be free from exploitation for the benefit or advantage of the provider;
terminate services at any time, except as otherwise provided by law or court order;
know the intended recipients of assessment results;
withdraw consent to release assessment results, unless the right is prohibited by law or court order or was waived by prior written agreement;
a nontechnical description of assessment procedures; and
a non-technical explanation and interpretation of assessment results, unless this right is prohibited by law or court order or was waived by prior written agreement.

Attestation to Contents of and Orientation to Bill of Rights

I have read and understand the Mental Health Bill of Rights

Demographic Information

Client Name:

Client Date of Birth:

Person Signing this form is: Client Parent/Guardian

Name of Person Signing this Form:

MNCP Logo

Your Privacy Rights

Client Name:

Client Date of Birth:

Person Signing this form is: Client Parent/Guardian

Name of Person Signing this Form:

THIS NOTICE DESCRIBES HOW PRIVATE INFORMATION, INCLUDING HEALTH INFORMATION, ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your health record contains personal information about you and your health. This information, which may identify you and relates to your past, present, or future mental and/or physical health is referred to as Protected Health Information (PHI). “Protected information” is individually identifiable information. We are committed to protecting the privacy of your health information by complying with applicable federal and state privacy and confidentiality laws. You have privacy rights under the Minnesota Government Data Practices Act, the federal Health Insurance Portability and Accountability Act (HIPAA), and other state and federal laws, rules, and regulations. These laws protect your privacy but also allow us to give information about you to others if the law requires or permits it. We are required by law to abide by the terms of this Notice of Privacy Practice and to provide you with this notice. We reserve the right to change the terms of this notice and apply any changes to all present and future information that we collect about you.

This Notice of Privacy Practices describes how we may use or disclose your protected information, with whom that information may be shared, and the safeguards we have in place to protect it. It also describes your rights regarding how you may gain access to and amend your protected information. You have the right to approve or refuse the release of specific information except when the release is required or authorized by law or regulation.

WHY DO WE ASK FOR PRIVATE INFORMATION?

We provide a number of mental health and other services. We may ask you for information so we can:

tell you from other persons by the same name or similar name,
determine service eligibility
make reports, do research, audit, and evaluate our programs,
collect money for payment
communicate with insurance companies,
collect money from the county, state, or federal government for help we give you
coordinate with the county social service agency that contract with us to provide your service

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED INFORMATION

Following are examples of permitted uses and disclosures of your protected information. These examples are not exhaustive. We may tell you before we release your information but are not required to in these instances.

Required Uses and Disclosures

By law, we must disclose your information to you unless it has been determined by a competent medical authority that it would be harmful to you. We must also disclose information to the Minnesota Department of Health and Human Services and the Secretary of the Department of Health and Human Services (DHHS) for investigations or determinations of our compliance with laws on the protection of your information.

Treatment/Services

Treatment is when we provide, coordinate, or manage your health care and other services related to your care. This includes the coordination or management of your care with an allowed third party. An example of treatment would be when we consult with another health care provider, such as your family physician. In emergencies, we will use and disclose your protected information to provide the treatment you require.

Payment

Payment is when we obtain reimbursement from insurance companies or other agencies/counties for your services. Your protected information will be used, as needed, to obtain payment for your services. This may include certain activities the County might undertake before it approves or pays for the services recommended for you such as determining eligibility or coverage for benefits.

Health Care/ Human Services Operations 

Operations are activities that relate to the performance and operation of our practice. Examples are quality assessment and improvement activities, program eligibility determination, and care coordination, along with business-related matters such as audits and administrative services, licensing inspections and government regulation requirements, investigations, and financial management of the organization. We may use or disclose, as needed, your protected information to support the daily activities related to health and human services care. We share your protected information with third-party "business associates" who perform various activities (for example; billing, referral sources). The business associates are also required to protect your information.

Required by Law

We may use or disclose your protected information if law or regulation requires the use or disclosure.

Legal Proceedings

We may disclose protected information during any judicial or administrative proceeding in response to a court order or subpoena.

Research

We may disclose your protected information to researchers/evaluators when authorized by law.

EXCEPTIONS TO PRIVACY AND CONFIDENTIALITY

In general, the law protects the privacy of communication between a client and a therapist. We only can release information about your treatment to others if you sign a release of information form. You can revoke any such authorization at any time in writing. However, in the following situations your authorization is not required for us to release information:

duty to warn a specific other in the case of potential suicide, homicide or threat of imminent, serious harm to another duty to report suspicion of abuse or neglect of children or vulnerable adults.
duty to report pregnant client exposure to cocaine, heroin, phencyclidine, methamphetamine, amphetamine or their derivatives, THC, and abuse of alcohol.
duty to report the misconduct of mental health or health care professionals.
duty to release records if subpoenaed by the courts.
duty to provide legal guardian/parents of minor children access to their child’s records. Minor clients can request, in writing, that particular information not be disclosed to parents.

Please discuss any questions or concerns you have about confidentiality with your provider at any time. If you have specific legal questions about the law regarding confidentiality, the exceptions, and how it may relate to your situation, please seek formal legal advice from an attorney.

YOUR RIGHTS REGARDING PROTECTED INFORMATION

Right to Inspect and Copy

You may inspect and obtain a copy of your protected information for as long as we are required to maintain it.

This right does not include inspection and copying of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected information that is subject to law that prohibits access to protected information.

Right to Request Restrictions

You may ask us not to use or disclose any part of your protected health information for treatment, payment, or health care operations. In your written request, you must tell us:

what health information you want restricted,
what use or disclosure you want to restrict
to whom you want the restriction to apply,
an expiration date

If we cannot reasonably accommodate the request, we are not required to agree. If the restriction is mutually agreed upon, we will not use or disclose your protected health information in violation of that restriction, unless it is needed to provide emergency treatment. You may revoke a previously agreed upon restriction, at any time, in writing.

Right to Request Alternate Communications

You may request that we communicate with you using alternative means or at an alternative location. We will accommodate reasonable requests, when possible.

Right to Request Amendment

If you believe that the information we have about you is incorrect or incomplete, you may request an amendment to your protected information as long as we maintain this information. While we will accept requests for amendment, we are not required to agree to the amendment.

Right to An Accounting of Disclosures

You may request that we provide you with an accounting of the disclosures we have made of your protected health information. This right applies to disclosures made for purposes other than services, treatment, payment or operations as described in this Notice of Privacy Practices. The disclosure must have been made after April 14, 2003, and no more than 6 years prior to the date of request. This right excludes disclosures made to you or others you authorized to receive information regarding your care.

FURTHER QUESTIONS OR COMPLAINTS

If you have any questions about the information we have about you, you may ask a staff person to tell you about it, or talk with your parent, guardian, or case manager.

You can contact Minnesota Care Partner’s Privacy Officer Katy Armendariz, CEO, 612.289.5656

You may also contact: Data Privacy Office, MN Dept. of Human Services, 4th Floor, Centennial Building, St. Paul, MN 55155. Phone # 651-297-3173.

ACKNOWLEDGMENT OF RECEIPT OF THIS NOTICE

We ask that you sign this form. Our intent is to make you aware of the possible uses and disclosures of your protected information and your privacy rights. If you decline to provide a signed acknowledgment, we will continue to provide you services, and will use and disclose your protected information for treatment, payment, and operations as disclosed in this notice.

Your signature is proof that you have received this form and understand what it says. If you have a guardian, they will be asked to sign for you. This notice about collecting and sharing information about you applies to all contacts we have with you when you are in our program, whether these contacts are in person, on the phone, electronic, or by mail.

 Attestation to Review and Understanding of Privacy Rights  I have received and reviewed the privacy rights.
  The privacy rights have been explained to me.

SIGNATURE:

Client or Parent/Legal Guardian: Date:

MNCarePartner: Date:

MNCP Logo

Minnesota CarePartner Services Agreement

Client Name:

Client Date of Birth:

Person Signing this form is: Client Parent/Guardian

Name of Person Signing this Form:

A. PERMISSION FOR TREATMENT

I agree to permit employees and interns of Minnesota CarePartner (MNCP) to provide services to me. I understand that Minnesota CarePartner can make no guarantees about the outcome of my treatment, but that I can expect to receive services that are ethical and professional. I understand that Minnesota CarePartner agrees to comply with all privacy laws and respects my right to confidentiality. As a client, I agree to attempt to be honest and to disclose information to assist the MNCP staff in providing appropriate services.

I agree to attend scheduled appointments or notify service providers if I need to reschedule an appointment.
I agree to participate in required treatment planning.
I understand that my diagnostic assessment and/or treatment may be being completed by a Licensed Mental Health professional, a Graduate level Clinical Intern Therapist, or a Master’s level Mental Health Practitioner who is being clinically supervised by a Licensed Mental Health professional.

B. HEALTH CARE SERVICES FINANCIAL AGREEMENT

I authorize Minnesota CarePartner to correspond with my insurance company as I have indicated, and with any insurance company with which I will be covered in the future to which I will ask Minnesota CarePartner to submit claims. I understand that it is my responsibility to know the benefits and limits of my insurance. I request payment of authorized insurance benefits be made to Minnesota CarePartner for any services furnished to me by any provider employed or contracted by this agency. I authorize Minnesota CarePartner to release to Minnesota Health Care Programs, its agents, or any insurance company, any information needed to process claims, determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize Minnesota CarePartner to release all information necessary to secure the payment.
Insurance claims will be handled as follows:
1. I do not want Minnesota CarePartner to file claims to my insurance company and I will pay fees in full upon receipt of an invoice for services.
2. I do not have insurance to cover services performed by Minnesota CarePartner and will pay fees in full upon receipt of an invoice for services or prior to services as required.
3. Minnesota CarePartner will file claims to the insurance I have indicated and I will pay any balance not paid by insurance. If my insurance is discontinued I will pay fees in full upon receipt of invoice for services.
If my insurance company sends me payment for services performed by Minnesota CarePartner and I have not yet paid my balance in full, I will make payment of at least the amount received from insurance within five working days.
This form also authorizes the release of any medical information necessary to process this claim. I understand that I am financially responsible for health care charges not covered by this authorization.
I hereby request and authorize direct payment of benefits specified under my policy or any policy paying benefits to: Minnesota CarePartner

C. ELECTRONIC COMMUNICATION

EMAIL COMMUNICATION I understand that e-mail is not a secure means of communication. I am aware that the provider may decline to communicate via e-mail based upon the nature of medical information. By providing my email address, I give permission to use electronic mail as a means of communication regarding my care. I understand that I may withdraw this authorization at any time by notifying Minnesota CarePartner staff or my provider in writing.

TEXT MESSAGING I understand that text messaging is not a secure means of communication. I am aware that the provider may decline to communicate via text messaging based upon the nature of medical information. I give permission for MNCP to use text messaging as a means of communication regarding appointment reminders, scheduling and reminders regarding paperwork. I understand that I may withdraw this authorization at any time by notifying Minnesota CarePartner staff or my provider in writing.

SOCIAL MEDIA:I understand that it is the policy of Minnesota CarePartner that providers will not interact with clients on any social media platform to protect my privacy.

D. Appointment Cancellation Policy Agreement

Minnesota CarePartner is committed to providing all of our patients with exceptional care. When a service recipient cancels without giving enough notice, they prevent another patient from being seen.
Please call your Provider on the day prior to your scheduled appointment to notify them of any changes or cancellations. If arriving late to a scheduled appointment, your late arrival will require that the session end at the scheduled time, meaning your session will unfortunately be shorter.
If prior notification is not given, you will be given three opportunities (due to no call/no show/ late cancellation) before your Provider decides on the continuation of services.

Under the above conditions, I provide my consent to receive services from Minnesota CarePartner

MNCP Logo

Minnesota CarePartner
393 N. Dunlap St.
St. Paul, MN 55104
P: 612-289-5656 F: 651-925-0278

Minnesota CarePartner/Roots Recovery allows, under certain conditions, the use of Telemedicine technology for Therapy and Skills sessions at the provider’s discretion and with the patient/client's consent. Telemedicine is not intended to be a complete replacement for face-to-face sessions and face-to-face sessions are expected to remain the primary mode of service.

Acceptable Reasons for the use of telemedical include such things as: Severe weather or transportation barriers making it difficult to travel to your clinician’s office, having to remain in home due to ill child, public health crisis, having your ride cancel at the last minute, scheduling conflicts or being out of town.

Keep in mind, however, that there might be certain clinical, ethical, or legal factors that would preclude or limit the use of Telemedicine. Your provider will discuss these factors with you on a case-by-case basis.

If you agree to participate in some sessions through telemedicine, please be reassured that all the standard issues related to privacy and confidentiality will still apply. However, please be advised that telemedicine uses the internet, which is not as secure as the privacy of your provider’s office and certain service providers might store copies of videos. It is possible that communication might be intercepted (hacked) or otherwise compromised. Additionally, telemedicine being a relatively new format, the empirical evidence for its efficacy, while promising, is limited.

Also, be aware that if you elect to not use telemedicine for therapy, this will not affect your ability to continue scheduling face-to-face sessions with your provider as available. Please ask your provider how telemedicine sessions factors into the no show, and late cancelation policy.

I agree to engage in sessions through telemedicine. I am aware of the potential limitations to privacy, confidentiality, and service connections associated with telemedicine.

I agree that I will take responsibility to ensure that I am in a place that allows sufficient privacy when engaging in telemedicine and that I will take every precaution to ensure that my confidential health information is protected on my end of the telemedicine connection.

MNCP Logo

Intake Forms Acknowledgement

Client Name:

Client Date of Birth:

Person Signing this form is: Client Parent/Guardian

Name of Person Signing this Form:

I attest that I have reviewed and understand the forms in this document, as listed below:

Minnesota CarePartner Mental Health Bill of Rights
Minnesota CarePartner Privacy Rights
Minnesota CarePartner Services Agreement

I agree to the information contained in each form to which I have attached my initial, attestation, or signature.

SIGNATURE:

If applicable:

MNCarePartner Staff:

MNCP Logo

Client Legal Name: Preferred Name:

Person Completing this form:

How do you identify your gender: Pronouns:

Parent/Legal Guardian Name (If under 18):

Are you a parent? YesNo

If yes, Child/Children names and ages:

Are you in a relationship right now? YesNo

Who do you live with right now?

What/Who are the support system(s) in your life? (ex: family/friends/church/school/community group etc):

What would you say are some of your strengths?

How would you describe your cultural background and influences?

How would you describe any spiritual or religious belief systems/practices?

Are you currently in school? YesNo

If yes, where and what grade/program?

Are you currently working?

YesNo

If yes, where and how long/how many hours/week?

How would you describe your physical health? (current/past conditions, medications etc):

How would you describe your family health history?

Please share any significant distressing or traumatic events happen in your life?

Have you ever had any thoughts or attempts at harming yourself?

YesNo

Any family history of substance abuse?

What substances have you used (How often/since what age):

Have you been in treatment for any substance use?

YesNo

If yes, when, and how was the experience?

CAGE-AID Chemical Health Assessment:

Have you ever felt that you ought to cut down on your drinking or drug use? YesNo

Have people annoyed you by criticizing your drinking or drug use? YesNo

Have you ever felt bad or guilty about your drinking or drug use? YesNo

Have you ever had a drink or used drugs first thing in the morning (eye-opener) to steady your nerves, get rid of a hangover, or get the day started? YesNo

If you have had mental health services before, when and where was that?

What is your main reason for seeking services right now?

What life changes or stressful events have been going on lately?

What days and times would you prefer to have counseling appointments?

Do you receive other services with us? ARMHS CTSS CSP Roots Other

Please select any symptoms you have experienced in the past six months:

Sadness/ tearfulness

Feeling down or depressed

Panic Attacks

Feelings of nervousness, tension or anxious

Worrying all the time

Racing thoughts

Skipping school/work

Staying out late

Sleeping too much

Sleeping too little

Trouble Falling Asleep

Trouble Staying Asleep

Acting out sexually

Being unhappy during or after sex

Trouble concentrating

Easily distracted

Poor attention

School Anxiety

Eating more often

Eating less often

Not feeling hungry

Under eating

Binge Eating

Making yourself vomit

Worried about weight: (too much weight or not enough)

Spending increased time alone

Social Anxiety

Self-Harming

Angry Often

Anger outbursts

Relationship stress with significant other/partner

Separation or divorce

Feeling Numb or Nothing

Feelings of loneliness

Low self-esteem/ low confidence

Getting into fights/arguing often

Loss of interest in previously enjoyed activities

Feeling or acting like a different person

Difficulty leaving your home

Mood swings

Repetitive behaviors (e.g. frequent checking, hand washing

Feeling hopeless and/ or helpless

Gender identity

Family problems

Trouble with Memory

Being tired during the day

Flashbacks

Hearing things that are not there

Sexual identity

Nightmares/ sleepwalk

Suicidal thoughts/ feelings

Thoughts or actual self-harm

Being abused

Seeing things that are not there

Issues with peers/friendships

Low Impulse Control

Finances

Being Bullied

Job/Work/Career Worries

Perfectionism

Making/keeping friends

Pregnancy

Parenting

Troubled about future plans

Thoughts about harming or killing someone else

Fire setting

Feelings of guilt

Unresolved grief/loss

Worried about a place to live

Religious/ spiritual concerns

Stealing

Other:

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February 17, 2022 12:18 am CDT

Adult Mental Health Intake Packet - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 206.84.190.22

February 17, 2022 12:23 am CDT

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