Please check (✓) each numbered item to confirm that you have received explanation and agree to its applicable statement. All statements are required

1. CONSENT TO TREAT: After clear explanation of program structure, rules, and expectations, I consent for the above-named client to receive services (MH/DD/SAS) from Restoration Family Services, Inc. (Restoration). I understand that this service is voluntary and that this consent may be withdrawn with written notification at any time. I understand that I will be actively involved in developing the Person-Centered Plan/Individualized Support Plan designed specifically to address identified needs.
2. PERSON CENTERED PLAN: I understand that I will be actively involved in developing the Person-Centered/Treatment Plan designed specifically to address identified needs. I agree to allow Restoration employees to implement professionally accepted methods of intervention and therapeutic strategies as indicated by the person-centered/ treatment plan that both the client/legally responsible representative and the service providers have developed. (For restrictive interventions, consent not to exceed 6 months)
3. MISSED APPOINTMENTS: The appointment times scheduled are assigned to provide services for me and/or my family member. I will make every effort to make the scheduled appointment in the office or be available via virtual to receive the service/treatment. If I need to cancel an appointment, I will call the clinical staff member working with me and/or the office at least 24-hours before the scheduled time. I do understand that three consecutive missed appointments (without notice) may result in termination of services. Also, I understand that if I “no-show” for an appointment without notice, I will be charged a $45.00 fee to be paid before next scheduled appointment.
4. TRANSPORTATION: I give permission and consent for the above person served to be transported by Restoration’s personnel for SAIOP only! The purpose of this transportation is to allow full participation in the delivery of Restoration services, as identified in the Person-Centered Plan/ Individualized Support Plan. I release Restoration Family Services, Inc. and its employees from any liability for accident or injury pursuant to such transportation.
5. SAFETY/FIRST AID: I have received information regarding the safety policies and the program rules and expectations of the person served. Also, I have received the information on how to contact staff after hours and given the emergency information (911) in order to receive assistance in case of an emergency during the day or after hours. I also authorize Restoration to provide and render first-aid assistance to the client as deemed necessary by trained staff.
6. MEDICATION MONITORING/DRUG SCREENING: : I consent to the collection and testing of my specimen to conduct medication/drug/alcohol screenings to better assess and refer to the appropriate level of care and treatment. For SAIOP services, drug screenings are mandatory for attendees, up to 3 times a week, and a minimal of once a week for Outpatient SA Group Therapy for individuals seeking help for substance use disorders. The results of the test will be confidential and released only to appropriate providers or agencies to better treat you, with your consent.
7. EMERGENCY CARE: I authorize Restoration to obtain emergency medical, dental or mental health care for the above-named consumer/patient. The care is authorized In the event that consumer (adult) or caregiver would be unable to be located to provide such consent. It is understood that the Restoration’s staff will attempt to locate caregiver, another legally responsible adult, or your designated emergency contact person as quickly as possible. In the event of an after-hours substance use, behavioral/mental health crisis/emergency, I have been given the information and encouraged to call or text the NC suicide and crisis lifeline 24/7 crisis line of “988” and Restoration’s 24-hour crisis line of (919) 912-2112.
8. CONSUMER/ PATIENT RIGHTS: I have had my Consumer/Patient Rights explained and had the opportunity to ask questions. I understand that if I feel my rights have been violated, I am encouraged to seek assistance or file a complaint with a member of Restoration’s leadership. I was also given information in how to file a complaint with Disability Rights of NC and the MCO.
9. HIPAA: The Notice of Privacy Practices was reviewed with me and I understand that Restoration has the right to revise the Notice of Privacy Practices as necessary and will notify me of any such changes. I am aware that I may obtain a copy of the original or revised Notice of Privacy Practices at any time. Also, I understand that my medical records are confidential but will be released if I am of harm to self or someone else.
10. INSURANCE STATUS: I understand that I am to present copies of my Insurance/Medicaid card. I will notify Restoration Family Services, Inc. of any changes that occur in my insurance status.
11. IPRS/STATE STATUS: My selection (✓) confirmed that I have no income and no health insurance; or I’m employed with no health insurance and I agree to submit proof of income for eligibility determination for IPRS/state funds.
12. TELE-HEALTH: My selection (✓) confirmed that I consent for tele-psychotherapy and/or tele-grouptherapy.TELE-HEALTH: My selection (✓) confirmed that I do not consent for tele-psychotherapy/tele-grouptherapy.
     Medical Care Decisions and Advance Directives: What you should know 13. ADVANCE DIRECTIVES: I have been given information for the, Medical Care Decisions and Advance Directives: What you should know, published by the North Carolina Department of Health and Human Services. I understand that if I choose to participate, I will notify my primary care provider and submit a copy of my decisions to be filed in my service record.
14. AMENDMENTS: I understand that this document may be amended on an “as needed” basis, and that any such amendment will require my signature or, as applicable, my legally responsible representative.
15. ACCEPTANCE: I have read and/or have had clearly explained to me the terms, conditions and agreements of this informed consent agreement and voluntarily accept them as stated above. This agreement may be withdrawn at any time and will not exceed one year after the date it was signed. Also, my signature below indicates that I have received orientation for the type of services that will be provided. I also hereby authorize treatment by the employees/contractors of Restoration. I hereby authorize Restoration to furnish minimally required information to my insurance, Medicare and Medicaid concerning my illness and treatments. My signature below indicates that I understand and accept this policy. I further authorize Insurance benefits to be paid directly to Restoration Family Services, Inc. I understand I can withdraw this consent/authorization at any time.

***Expiration Date of Informed Consent for Service Delivery will expire one year from signature date unless otherwise stated.

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Stand: 03/19/2021