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Intake Documents

Elite Recovery, LLC • 1137 Grand Ave. Saint Paul, MN 55105 • (612) 719-4137

Client Bill of Rights & Client Welfare Acknowledgement
Per Minnesota Statute 148F.165

Client Name:
Client Date of Birth:

Your Primary Counselor:

Counselors:
Kelsey Gregg LADC, License #305331, Elite Recovery, LLC, 1137 Grand Avenue, Saint Paul, MN 55105. Contact number (612) 257-2391
David Smith, LADC, License #302926, Elite Recovery, LLC, 1137 Grand Avenue, Saint Paul, MN 55105. Contact number (651) 262-3981
Ava Drake, LADC, License #305874, Elite Recovery, LLC, 1137 Grand Avenue, Saint Paul, MN 55105. Contact number (651) 508-0776
Choice Pickins Newstrom, ADC-T, Elite Recovery, LLC, 1137 Grand Avenue, Saint Paul, MN 55105. Contact number (612) 444-6624

Counselor’s Supervisor:
Justin Scharr, LADC License #304757, Elite Recovery, LLC 1137 Grand Avenue, Saint Paul, MN 55105, Contact number (612) 500-1269.

Fees and Billing: Billing is performed by the business office of Elite Recovery, LLC located at 1137 Grand Avenue, Saint Paul, MN 55105. A description of fees and costs of services is given to each client at the initiation of services. If you need another copy, please request one.
This is a Rule 25 funded program licensed by the State of Minnesota and all of our participants receive funding through the consolidated treatment block grant fund, private insurance or self-pay. Rule 25 clients are not responsible for partial payment of services.

Theoretical Approach: Address each participant as an individual addressing their current needs. Treatment plans are developed in the six dimensions defined by the American Society of Addiction Medicine. Person centered goals are identified by participants with LADCs providing assistance to develop objectives to meet those goals. The program utilizes evidence-based counseling strategies including cognitive behavioral counseling, illness management, recovery and stage-based interventions, and a Twelve Step recovery model is encouraged. Each person will address their substance use and mental health needs based on their current stage of change, moving towards self-sufficiency at every level and improving quality of life that in the past has been hampered as a result of mental health concerns and substance use.

Other Services: Other community health or social services may be available to assist in addressing your needs. For more information, ask your counselor or any staff member.

Consumers of alcohol and drug counseling services have the right:

To expect that the provider meets the minimum qualifications of training and experience required by state law;
To examine public records maintained by the Board of Behavioral Health and Therapy that contain the credentials of the provider;
To report complaints to the Board of Behavioral Health and Therapy, 2829 University Ave. SE, Suite 210, Minneapolis, MN 55414, 612-548-2177;
To be informed of the cost of professional services before receiving the services;
To privacy as defined and limited by law and rule;
To be free of being the object of unlawful discrimination while receiving counseling services;
To have access to records as provided in section 144.92 and 148F.135 subdivision 1, except as otherwise provided by law;
To be free from exploitation for the benefit or advantage of the provider;
To terminate services at any time, except as otherwise provided by law or court order;
To know the intended recipients of assessment results;
To withdraw consent to release assessment results, unless the right is prohibited by law or court order or was waived by prior written agreement;
To a non-technical description of assessment procedures; and
To 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.

Stereotyping. The provider shall treat the client as an individual and not impose on the client any stereotypes of behavior, values, or roles related to human diversity.

Misuse of client relationship. The provider shall not misuse the relationship with a client due to a relationship with another individual or entity.

Exploitation of client. The provider shall not exploit the professional relationship with a client for the providers emotional, financial, sexual, or personal advantage or benefit. This prohibition extends to former clients who are vulnerable or dependent on the provider.

Sexual behavior with client. The provider shall not engage in any sexual behavior with a client including:

sexual contact, as defined in section 604.20 subdivision 7; or
any physical, verbal, written, interactive or electronic communication, conduct, or act that may be reasonably interpreted to be sexually seductive, demeaning, or harassing to the client.

Sexual behavior with a former client. A provider shall not engage in any sexual behavior within the two-year period following the date of the last counseling service to a former client. This prohibition applies whether or not the provider has formally terminated the professional relationship. This prohibition extends indefinitely for a former client who is vulnerable or dependent on the provider.

Preferences and options for treatment. A provider shall disclose to the client the provider’s preferences for choice of treatment or outcome and shall present other options for the consideration or choice of the client.

Referrals. A provider shall make a prompt and appropriate referral of the client to another professional when requested to make a referral by the client.

If you have insurance benefits, we will be billing your insurance company for you. Rates for various third-party payers vary as determined by contracts. You will be responsible for your co-pays at the time of service. We will verify your insurance benefits prior to your admission to the program to give you an idea of the estimated amount your insurance has informed us they may pay.

The insurance companies will not and do not guarantee payment on any policyholders. This is just an estimate. In the event we do not hear from the insurance company, we will contact you for clarification or assistance in collecting from them. If there is a need for a payment plan of any kind, it must be approved by our business office. For your convenience, we accept major credit cards. You will be responsible for any amount your insurance does not cover.

Some of the insurance companies we work with are, BlueCross & BlueShield, Cigna, Health Partners, Preferred One, CCS/TEAM, UCare Minnesota, United Behavioral Health/Medica, United Healthcare, and Value Options.

By signing this agreement, you are acknowledging that you have received the Client Bill of Rights.

Attestation:

  I attest that I have received a copy of and understand the client bill of rights.

Elite Recovery, LLC • 1137 Grand Ave. Saint Paul, MN 55105 • (612) 719-4137

Confidentiality of Alcohol & Drug Abuse Records

Client Name:
Client Date of Birth:

The confidentiality of alcohol and drug abuse client records maintained by this program are protected by Federal law and regulations. Generally, the program may not confirm or deny to anyone outside the program that a client attends the program, or disclose any information identifying a client as an alcohol or drug abuser

UNLESS:

The client consents in writing;
The disclosure is allowed by a court order; or
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.
The disclose is made for mandatory reporting or duty to warn related to self harm/harm to others.

Violation of the Federal law and regulation by a program is a crime. Suspected violations may be reported to the United States Attorney for the judicial district in which the violation occurs in accordance with Federal regulations.

Federal law and regulations do not protect any information about a crime committed by a client either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or Local authorities.

  I acknowledge that I have been oriented to and understand the confidentiality policies.

Elite Recovery, LLC • 1137 Grand Ave. Saint Paul, MN 55105 • (612) 719-4137

Notice of Privacy Practices

Client Name:
Client Date of Birth:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.

As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
The right to receive an accounting of disclosures of protected health information.
The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

The notice is effective as of April 1, 2020 and we are required to abide by the terms of the Notice Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protection have been violated. You have the right to file written complaints with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information.

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619- 0257
Toll Free: 1-877-696-6775

  I acknowledge receipt of and orientation to the privacy practices.

Elite Recovery, LLC • 1137 Grand Ave. Saint Paul, MN 55105 • (612) 719-4137

Telemedicine Informed Consent

Client Name:
Client Date of Birth:

I understand that my substance use provider requires I engage in telehealth for group sessions and individual sessions.
My substance use provider has explained to me how the video conferencing technology will be used to facilitate group and individual sessions and will not be the same as a direct client/substance use provider visit since I will not be in the same room as my substance use provider.
I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my substance use provider or I can discontinue the telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
I have had the alternatives to a telehealth session explained to me, and in choosing to participate in a telehealth session.
I understand that billing will occur in the same format as if I were on site.
I have had a direct conversation with substance use provider, during which I had the opportunity to ask questions regarding telehealth substance use treatment. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
I understand my substance use provider is using a HIPAA compliant platform.

By attesting to my review of this form, I agree:

That I have read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of treatment.
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

  I attest to the above statements with regard to the telemedicine policy

Elite Recovery, LLC • 1137 Grand Ave. Saint Paul, MN 55105 • (612) 719-4137

Group & Attendance Guidelines

Client Name:
Client Date of Birth:

Please text our main number if you're going to be late or miss group for any reason. 612.719.4137 This is monitored by all staff who may be facilitating group. You can also primary counselor:

Morning Group: Kelsey Gregg at (612) 257-2391
Morning Hybrid & Extended Care Group: Choice Pickins at (612) 444-6624
Evening Group: David Smith at (651) 262-3981

To help the group stay focused, please observe the following:

Be on time.
Come to group sober and do not have the smell of alcohol or drugs on clothing or breath.
Do not leave group early. Let rides know that you will not be allowed to leave early.
Refrain from use of cell phone during group, including no photographing, audio or video recording.
Please stay in the room until break. Plan to get coffee, use the bathroom, take medications before group or on break.
If you arrive late, come into the room quietly and be seated immediately. Do not get a beverage until break.
No eating during group time.
No smoking, chew or e-cigs/vaping in the building.
Parking behind the building is for staff only. Unauthorized vehicles will be towed at owner’s expense.
Throw away all trash after group or on break, and make sure coffee area and bathroom are clean.
Come to group ready to participate actively.
Be mindful of clothing choices:
1. Clothing needs to cover chest and backside.
2. Clothing needs to be free from logos promoting alcohol, drugs, sexual situations, and violence.
Attendance in group and individual sessions is vital to your growth and recovery.
1. Please contact your counselor ahead of time before you will be late or absent.
2. Ongoing tardiness and absenteeism will lead to consequences and/or discharge.
3. Attendance is based on required number of group sessions and weekly 1 hour individual session. If you miss any more than 3 groups during the duration of treatment, you will be discharged from the program.
4. Discharge from the program is on a case by case basis.
5. Clients who are discharged must wait 30 calendar days before they are eligible to re-admit to the program.
6. Please note that attendance guidelines for those living in sober housing and receiving rent credit are very strict. ANY unexcused absences from group or individual sessions may lead to loss of housing credit.
Please refrain from intimate or private relationships with other group members that may interfere with group process.
During group, one person speaks at a time. Please be mindful of the amount of time you spend sharing.
Confidentiality-what’s shared here, stays here. No talking about other group members outside of group even if you are with other group members as you can’t guarantee who is listening.
Use “I” statements. Speak from your own experience. Give feedback, not advice (including medical or psychological referrals)
Be respectful of the opinions and feelings of others.
Any violent, threatening, intimidating, disrespectful or illegal behavior toward other clients or staff will not be tolerated and may be grounds for immediate discharge.
All group rules are at the interpretation and discretion of Elite Recovery staff.

As a participant in the Elite Recovery program, expect to learn and grow and challenge ourselves. Staff and your peers are here to support your healing and recovery.

  I understand the group guidelines and have had the opportunity to ask questions or get clarification.

Elite Recovery, LLC • 1137 Grand Ave. Saint Paul, MN 55105 • (612) 719-4137

Impairment Agreement
Client Name:
Client Date of Birth:

Should I arrive to group impaired or under the influence of chemicals, I will be asked to meet individually with staff, and choose one of the following:

Cab to Detox
Cab to home (unless I live in Recovery Homes of MN)
Public transportation to home (unless I live in Recovery Homes of MN)
Call someone to pick you up
Call house manager of Recovery Homes of MN to transport to detox or safe place

If you drove to group under the influence and leave in your vehicle, we are obligated to call the authorities.

We welcome you back to the next group session. If you should have questions or concerns, please feel free to contact our staff at any time.

  I attest to my understanding and acceptance of the impairment agreement.

Elite Recovery, LLC • 1137 Grand Ave. Saint Paul, MN 55105 • (612) 719-4137

Permission to Receive Services

Client Name:
Client Date of Birth:

I, , acknowledge that these policies have been reviewed with me and I was given a copy of all information in the Elite Recovery intake packet as listed below and hereby give my permission to Elite Recovery to provide me with treatment or any other services that might be related to my chemical dependency. The treatment process, discharge planning process and referral process have been explained to me and I had an opportunity to ask questions.

Vulnerable Adult Disclosure Consent offered
Vulnerable Adult/Individual Abuse Prevention Plan
Vulnerable Adult/Mandated Reporting Information
Orientation to Program Abuse Prevention Plan
Tennessen Warning
Service Termination and Transfer Policy
Risks Associated with Treatment/Fee Policies
Client Bill of Rights/Grievance Procedure
Program Guidelines/Expectations/Responsibilities
Data Privacy and Confidentiality Information
Policies and Procedures Regarding AIDS/HIV/TB
Information on Opioid Treatment Options & Overdose Prevention
Telemedicine Policy & Procedure
Group & Attendance Guidelines

By signing below, I acknowledge that I agree to the following agreements, consents, and documents. A copy of all relevant information is posted in the group room, if I may have any questions regarding these forms.

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January 20, 2021 9:23 am CST

Intake Documents Uploaded by Justin Scharr - justin@eliterecoverymn.com IP 24.118.59.35

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Client Bill of Rights & Client Welfare AcknowledgementPer Minnesota Statute 148F.165Client Name: Client Date of Birth:

Client Name: Client Date of Birth:

Client Name: Client Date of Birth:

Telemedicine Informed Consent

Client Name: Client Date of Birth:

Group & Attendance Guidelines

Client Name: Client Date of Birth:

Impairment AgreementClient Name: Client Date of Birth:

Permission to Receive Services

Client Name: Client Date of Birth:

Client Bill of Rights & Client Welfare Acknowledgement
Per Minnesota Statute 148F.165

Client Name:
Client Date of Birth:

Client Name:
Client Date of Birth:

Client Name:
Client Date of Birth:

Client Name:
Client Date of Birth:

Client Name:
Client Date of Birth:

Impairment Agreement
Client Name:
Client Date of Birth:

Client Name:
Client Date of Birth: