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Pacific Health Education Cognitive Center Inc

Intake Packet

Introduction

Welcome to Pacific Health Education Cognitive Center (PHECC) We look forward to working with you. We believe the following information will be helpful with establishing a good therapeutic relationship between PHECC and the Client. Please read the information provided carefully, and feel free to ask any question that you may have.

Professional Background:
At PHECC, you will be served by our personnel which may include licensed professionals as well as experienced mental health workers. It is our goal to work together as a team to provide each patient with high quality services.

Initial Appointment:
Your initial appointment is considered a diagnostic interview. Based on the information obtained on the first-time visit, we (PHECC) will decide together whether the services provided are appropriate for the client. It will discuss the type of therapy each client will need including (individual therapy). It will also be determined if the client qualifies for SUD, IOP or PHP treatment services.

Appointments:
Individual therapy sessions typically last 45-55 minutes but may be shorter or longer according to the needs of the client. All appointments are scheduled directly in person or by phone. If you feel you need to cancel your appointment, please give us as much notice as possible.

Groups:
Group sessions typically last between 45-55 minutes however they may go longer according to the needs of the group.

Payments:
If you have insurance, PHECC will bill them directly. This includes Medicare and MediCal insurance. If you prefer to pay directly, please discuss this with our Billing Coordinator or Administrator.

Confidentiality:
All information regarding the specific nature of your individual therapy, treatment, groups, services, etc. are considered confidential unless otherwise specified in writing with an Authorization to Release Information (ROI). However, we do reserve the right to use specialty consultation and other therapy as needed regarding general aspects of therapy.

Please keep in mind that we are mandated reporters and that confidentiality may be broken when a client behaves in such a way that poses threat of physical harm to another person or to self. California law requires professional to report suspected incidents of child abuse or neglect to the proper protective serving agency. This also includes any form of elder abuse.

Conditions for Disenrollment, Discharge or Termination:
As you reach your goals in therapy, groups, and treatment, a gradual tapering of sessions will occur as it pertains to individual therapy sessions. Group therapy and educational services will continue 5 days per week until it has been determined by our medical professional that the client no longer requires services with our program. Once the medical professional deems the client is no longer fit for the program, our social services department may provide the client with additional resources to maintain success with their treatment.

If a client misses 7 consecutive days of treatment and no contact has been made with the client a 10-day letter to discharge will be mailed to the client which allows them 10 days to reconnect prior to discharge. If the client does not respond to the 10-day letter, the client will be discharged from the program. However, the client may re-enroll in the program at any time post evaluation from our medical professional(s).

Emergencies:
If an emergency crisis occurs after program hours of operation, please call the crisis helpline at (800)-991-5272, which provides 24-hour crisis intervention services. The emergency room of the closest hospital is also another resource to utilize during a time of crisis.

I acknowledge that I have read and understand all the above-mentioned statements and that my signature below indicates that I agree to abide by all the above conditions.

Patient Agreement

Services:
The Cognitive Center, (PHECC) fully evaluated my medical/psycho-social condition and have deemed that I am appropriate for admission into the program. My treatment plan will be reassessed every 30 days, however a report of my progress will be completed on a quarterly basis, which will be based on the initial admission date. Any changes made in my treatment plan will be discussed with me but will not necessitate my signing of another Patient Agreement. I understand that the minimum hours of attendance are 20 hours per week, however I understand that the hours are subject to change if necessary and can be adjusted to meet each patient’s needs.

The initial treatment plan has been discussed with me and I understand that services will be provided according to my treatment plan.

Non-Discrimination:
Services shall always, be provided without discrimination regarding race, color, religion, age, sex, national origin, ancestry, or physical or mental handicap. Furthermore, Patients who have or are perceived of having AIDS or AIDS related conditions will not be refused services based solely on their diagnosis.

Conditions for Disenrollment:
I understand that my participation in the PHECC program is voluntary, and I may discontinue participation in the program at any time by notifying the PHECC staff, declaring my intentions either orally or in writing. I further understand that PHECC may discontinue my participation in the program under the following conditions:

  • If I move from the designated service area permanently,
  • If I have made maximum use of the services and there is no future need of additional services, determined by the PHECC multi-disciplinary team,
  • If I am unable or unwilling to use the prescribed services and the PHECC team has made every effort to assist me.

Grievance Procedures:
The PHECC grievance procedures have been explained to me and I understand that if I am dissatisfied with the treatment plan or services by PHECC, I may file a formal grievance with the Administrator. If I am not satisfied with the center’s resolution to my grievance, I have a right to a fair hearing with California CMS.

Medicare Beneficiary:
If I am a Medicare recipient, I understand that the PHECC services must be approved by the State and that the PHECC will be paid by the Medicare Program. I grant permission to PHECC to transfer me to a hospital or other health facility in case of emergency. (See Authorization for Emergency Medical Care)

I understand that at any time, I may request a copy of this form for my personal records.

Notification of Services

I hereby acknowledge that by attending PHECC Intensive Outpatient Program, I will be participating in the below mentioned services:

  • Educational Curriculum
  • Group Therapy
  • Therapeutic Exercises
  • Recreational Activities
*Note services are subject to change

I also understand that I am required to attend Program 12 hours per week, 3 days per week. I understand that the staff of PHECC will be providing the identified services and any additional services while under the supervision of the Medical Director, Psychiatrist and/or LCSW/LMFT.