Jefferson County Youth Alcohol Intervention Program



Jefferson County Youth Drug and Alcohol Prevention Program

Denver Family Therapy Center, Inc.

________________________________ ___________

Please Print Name (Youth) Date of intake

_____________________________________________________________

Address include City, State and ZIP code

Gender (circle one): M F Transgender Other

Date of Birth

_____________________

County of Residence

Are you covered under medical insurance? Yes or No

Insurance Provider __________________________________________

Does medical insurance cover substance treatment? Yes or No

Have you ever received treatment for substance abuse before? Yes or No How many times ?

Highest School Grade Completed ____________

Race/Ethnicity (youth) ____________________

________________________________ ____________________________________

Race/Ethnicity (guardian #1) Race/Ethnicity (guardian #2)

Are you employed? Yes or No Are you married? Yes or No

Are you or could you be pregnant? Yes or No

Sexual Orientation (circle one): Bisexual Gay/Lesbian Heterosexual Other Decline

Number of people living on the Client’s(youth’s) income ______?

Client Lives with parent ____ Client lives independently____ (check one)

Custody arrangement (if applicable)________________________________________?

Have you had an MIP (minor in possession) in Jefferson County before? Yes or No

Was the MIP for: alcohol , marijuana or paraphernalia?__________________

Have you ever been to detox? Yes or No Number of times______?

Do you have current mental health problems? Yes or No

Have you experienced or witnessed a traumatic event? Yes No Unsure

Have you visited a medical emergency room in the last 30 days? Yes or No

Have you visited a psychiatric emergency room in the last 30 days? Yes or No

Have you visited a psychiatric emergency room in your life? Yes or No

Have you had a DUI/DWAI in the last 30 days? Yes or No

Number of arrests in the last 30 days? ______

Have you had a DUI/DWAI in your life? Yes or No

Number of arrests in lifetime? ______

Have you been to a self-help program in the last 30 days? Yes or No How many times? _____

Have you been to a self-help program in your lifetime? Yes or No How many times? _____

Do you smoke cigarettes/use tobacco? Yes or No

(Circle one) Current smoker/tobacco user Former smoker/tobacco user Never smoker/tobacco user

Unknown if ever smoked/ used tobacco

Family living situation (circle one):

2 parent biological 1 biological parent, single

1 biological parent + other (blended, step family etc.) Non-parent kin

Grandparents (circle either maternal or paternal) foster care

Same sex parents: Single or 2 Parents

Other, please describe:__________________________________________________

Adopted: Yes/ No

Parent/Guardian #1:

_______________________________ _____________ ______________

Name of parent/Guardian #1 Date of Birth Gender

Are you employed? Yes or No Are you married? Yes or No

Highest level of education? ______________ Occupation? __________________________

________________________________________________________________________

Address include City, State and ZIP code

Estimated household income?__________________________

Parent/Guardian #2:

_______________________________ _____________ ______________

Name of parent/Guardian #2 Date of Birth Gender

Are you employed? Yes or No Are you married? Yes or No

Highest level of education? ______________ Occupation? __________________________

________________________________________________________________________

Address include City, State and ZIP code

Estimated household income?__________________________

DENVER FAMILY THERAPY CENTER, INC.

CO-DIRECTORS 4891 INDEPENDENCE # 165

DAVID BLAIR, LCSW, CAC III WHEAT RIDGE, CO 80033

ROBERT KELSALL, LCSW PHONE: 303-456-0600

FAX: 303-456-0607

Y-DAP Authorization for Use or Disclosure of Health Information

Patient Name: __________________________________ Patient Date of Birth: _________________________

By signing this form you are giving permission for the Jefferson County Youth Drug and Alcohol Prevention program to release confidential information to the party (or parties) initialed below.

The only information that will be released is the following:

• Status of program completion including non-compliance.

• If you were flagged for a follow-up appointment

____Municipal Court – Please fill in which court your ticket is from:_____________________________________

____ School- Please fill in which school required you to complete the program:_____________________________

Name and phone number of school contact:___________________________________________________

____ Probation Officer: Name and phone number of probation officer____________________________________

The Purpose of this Request is: To coordinate program completion status to relevant parties

This authorization will expire on (Date): _______________ Or if left blank, one year from today.

I hereby authorize the use of disclosure of my protected health information as specified above. I understand that this authorization is voluntary and that I may refuse to sign it. I understand that I may revoke this authorization at any time by giving written notification to my provider or any member of the office staff. A revocation will not affect any action taken in reliance on the authorization prior to the revocation. Other limitations on my right to revoke this authorization may be found in my providers’ Notice of Privacy Practices. I understand that, if the recipient is not a health care provider or a health plan, the information disclosed under this authorization may no longer be protected by federal privacy regulations & may be re-disclosed by the recipient. I understand that I should receive a copy of this authorization, even if I do not ask for it.

I understand that treatment may not be denied if I refuse to sign this authorization, except: 1) If the authorization is the very reason for seeking the health care (e.g., a pre-employment physical), that health care may be denied; or 2) If the authorization is for disclosure to a research study, I may be denied the treatment that is part of the study. In addition, the following consequences might occur if I refuse to sign the authorization: 1) If the authorization is to demonstrate to a health plan that a service should be paid for, the health plan may refuse to pay for it, and 2) If the authorizing is sought by an insurer because I am seeking enrollment or eligibility, the insurer may deny me the coverage I am seeking. I understand that a health plan my not refuse payment or benefits if I refuse to authorize disclosure of certain psychotherapy notes.

42 CFR§ 2.1 Statutory authority for confidentiality of drug abuse patient records. The restrictions of these regulations upon the disclosure and use of drug abuse patient records were initially authorized by section 408 of the Drug Abuse Prevention, Treatment, and Rehabilitation Act (21 U.S.C. 1175). That section as amended was transferred by Pub. L. 98–24 to section 527 of the Public Health Service Act which is codified at 42 U.S.C. 290ee–3. This statue includes “Confidentiality of patient records.”

_____________________________________________ ________________________________________

Client Signature Date

_____________________________________________ ________________________________________

Parent Signature Date

_____________________________________________ ________________________________________

Program Staff Date

Payment Record

Jefferson County Youth Drug and Alcohol Prevention

Denver Family Therapy Center, Inc.

________________________________ ___________

Please Print Clients Name Date of intake

_____________________________________________________________

Address include City, State and ZIP code

______________ Gender: Male/ Female

Date of Birth

------------------------------------------------------------------------------------------------------------------------------

***Staff will complete bottom portion***

Method of Payment Cash Credit Card Date paid______________

(circle one) Received by_____________

Amount paid ____________

Attach money or credit card slip to this paper.

CONSENT FOR COMMUNICATION OF PROTECTED HEALTH INFORMATION

BY NON-SECURE TRANSMISSIONS

This consent form is for the communication of Protect Health Information that Denver Family Therapy Center, Inc. (hereinafter “DFTC”) may transmit without the written authorization of the client as described in the Uses and Disclosure section of DFTC’s Notice of Privacy Policies and Practices.

I,____________________________, hereby consent and authorize DFTC to communicate my protected health information through the following non-secure transmissions (please initial your choices):

_________ Cellular/Mobile Phone

Phone Number___________________________________________________

Second Phone Number (if needed):___________________________________

_________Unsecured Email

Please Provide Your Email:_________________________________________

Please Circle One: Work or Personal

Should we agree to communicate by the approved communications listed above, i.e. text, email, telephone confidentiality extends to those communications. However, I cannot guarantee that those communications will remain confidential. Even though I may utilize state of the art encryption methods, firewalls, and back-up systems to help secure our communication, there is a risk that our electronic or telephone communications may be compromised, unsecured, and/or accessed by a unintended third-party.

I, ___________________, understand that DFTC may use and disclose the following protected health information without my written authorization. However, I consent to DFTC transmitting the following protected health information by the above selected electronic communications (please initial your choices):

__________Information related to scheduling

__________Information related to billing and payments

__________Information related to your substance abuse classes or treatment

__________Other Information. Please Describe:___________________________________

____________________________________ ______________________

Signature of Client DATE

____________________________________ ______________________

Signature of Parent or Guardian DATE

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