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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