Required Documents Prior to Admission

Required Documents Prior to Admission

ALL DOCUMENTATION MUST BE SUBMITTED TO QP/MCO WITHIN 14 DAYS OF VERBAL COMMITMENT TO PLACE CONSUMER. OTHERWISE BED MAY BE OPENED TO OTHER POTENTIAL CONSUMERS

1. Custody Order/DSS (If applicable)
2. Updated PCP
3. Psychological Evaluation/CCA
4. Court Records (If applicable)
5. Medicaid Card
6. Social Security Number
7. Immunization Record
8. Current Prescriptions
9. Birth Certificate
10. School Records
11. IEP (If applicable)
12. Documentation of current progress if in level IV
13. Proof of place identified for treatment of current substance abuse issues (If applicable)
14. CALOCUS Documentation
15. Discharge Plan
16. Recent Physical

Please include the following in the PCP/Crisis Plan for your consumer:

Please instruct staff to request a CIT trained officer when calling police to respond to a MH/IDD/SAS crisis.

Dreams and Visions, LLC

Client Face Sheet

Admission Date:______

Client Name: ______

Services:Residential Level III

Facility:Dreams and Visions, LLC

5004 Glenview Court

Charlotte, NC 28215

(704) 566-9734

Record Number:______

Medicaid #:______

SS#:______

DOB:______

Race:______

Age:______

Eyes:______

Height:______

Weight:______

Identifying Marks: ______

Gender:Female

Last Physical Exam: ______

Last Dental Exam:______

Last Eye Exam: ______

EMERGENCY CONTACTS

Guardian Name: ______

Guardian Address:______

______

Guardian Phone:______

Therapist:______

Phone:______

Medications: ______

Allergies:______

Medical Alerts (Check all that apply):

Seizures

Hepatitis B Carrier

Diabetes

Hypertension

Hyperthyroid

Tuberculosis

Other ______

Special Diet:______

Primary Physicians: Teen Health

3541 Randolph Rd #206
Charlotte, NC 28211
(704) 381-8336

Behavioral Issues (Check all that apply):

Physical Aggression

Verbal Aggression

Property Destruction

Other Behaviors ______

Communication:

Level______

Method______

Vision______

Hearing______

Responds to own name (Check One):

Yes

No

Emergency: University Hospital

8800 North Tryon St.

Charlotte, North Carolina 28262

704-863-6000

Diagnosis:

Primary:

 289.9 296.32 296.34 296.9300304.30 307.60

 309.81 312.82313.81314.01314.09 ______ ______

 ______ ______ ______ ______ ______ ______ ______

Secondary (check all that apply):

 289.9 296.32 296.34 296.9300304.30 307.60

 309.81 312.82313.81314.01314.09 ______ ______

 ______ ______ ______ ______ ______ ______ ______

Dreams and Vision, LLC

Accepts Notice:

Dreams and Vision, LLC

Client:Record No.

VOLUNTARY PLACEMENT AGREEMENT

I, , parent or legal guardian of ,

child’s date of birth am aware that my child is placed under the care of Dreams and Vision, LLC at the location of 5004 Glenview Court located in Mecklenburg County, Charlotte, NC 28215 on the date of ______. This Voluntary Placement Agreement is temporary and can be revoked by me after consolation with the staff within ______days.

I also give permission to Dreams and Vision, LLC staff to transport my child to any activities, which are a part of the program, as well as to the required medical, dental, mental health, and/or educational services. I also give Dreams and Vision, LLC permission to enroll my child in school and act as my representative for educational purposes.

Dreams and Vision, LLC staff is to arrange for proper supervision and care for my child while in residence and agree to keep me informed of my child’s adjustment and progress while in residential care. I, the parent or the legal guardian, understand that I am responsible for providing the following: ______

______

______

Parent/Guardian Date

Dreams and Vision, LLCDate

DREAMS AND VISIONS, LLC

Consent for Services/ Routine Medical Treatment/Emergency Care Consent

Name of Individual: ______Record Number: ______

Consent for Services: I authorize Dreams and Visions, LLC to provide/seek care and treatment of services to my child/ child of whom I am guardian. These services may include but not limited to: Routine physical, medical treatment, psychiatric treatment, psych-education, mentoring, adaptive skill training, community integration, support counseling, behavioral management, crisis intervention, personal care, medication administration, etc.

Emergency Care Consent: I give Dreams and Visions, LLC permission to obtain emergency care for my child/child I am guardian. Every effort will be made to honor the individual/parent/guardian choice of physician/hospital/dentist. However, should an emergency arise that requires immediate assistance, the Dreams and Visions employee will either call for emergency assistance through 911 or transport the client to the nearest emergency room or urgent care center.

I understand the consent may be withdrawn at any time.

My signature below indicates I have read and understand this release/consent form and I have signed it of free will.

Parent/Guardian Signature: ______Date: ______

Witness: ______Date:______

APPROVED CONTACT LIST

Please list below approved contacts for consumer. Please note that during the 30 day probationary period no contact will be allowed. Guardians may call facility to check on their child but they will not be able to speak to them until 30 day probation is complete. Consumers are allowed to speak with therapist, court counselor, probation officer, or dss worker during this probationary period.

Contact Name: ______

Contact Phone Number: ______

Relationship to Consumer: ______

Contact Name: ______

Contact Phone Number: ______

Relationship to Consumer: ______

Contact Name: ______

Contact Phone Number: ______

Relationship to Consumer: ______

Contact Name: ______

Contact Phone Number: ______

Relationship to Consumer: ______

Contact Name: ______

Contact Phone Number: ______

Relationship to Consumer: ______

Contact Name: ______

Contact Phone Number: ______

Relationship to Consumer: ______

Dreams and Vision, LLC

CONSUMER CHOICE OF SERVICES AND PROVIDERS

DREAMS AND VISIONS, LLC is committed to ensuring that clients have the right to choose the application of the service they qualify for, to decide the provider of the services they qualify for, and to select, if they desire, a change in services and/or providers.

By signing this form, you are stating you understand that you as the client have the right to choose relevant services and which provider delivers those services and that DREAMS AND VISIONS, LLC has provided you that choice. Further, you acknowledge that no DREAMS AND VISIONS, LLC staff employees have in any way advertently or inadvertently influenced your choice services providers.

Services Qualified for:Chosen Provider:

Residential Level IIIDreams and Vision, LLC

TherapyTeal Peoples, LCSW, LCAS

Medication Management______

Day Treatment______

Partial Hospitalization______

Other ______

I understand that DREAMS AND VISION, LLC has not influenced my decision in any way.

Client Name: ______Date: ______

Client Record Number: ______

Client Guardian: ______Date: ______

Witness Signature: ______Date: ______

Dreams and Vision, LLC

CONSENT TO RELEASE OR EXCHANGE INFORMATION AUTHORIZATION

I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange):

PURPOSE OF RELEASE (check reason): Request of individual/personal Continued patient care Insurance
Legal purpose including discussions & proceedings Other ______

Provide specific meaningful description of the information to be used-disclosed: ______

______

______

I understand that this authorization will expire on the following date, event, or condition: ______

(NOT TO EXCEED ONE YEAR)

Restrictions (Specify): ______

I understand that if I fail to specify an expiration date or condition, this authorization is valid for the period of time needed to fulfill its purpose for up to one year, except for disclosures for financial transactions, wherein the authorization is valid indefinitely. I also understand that I may revoke this authorization at any time by signing the Revocation Section on the bottom of this form. I further understand that any action taken on this authorization prior to the rescinded date is legal and binding. I understand that my information may not be protected from re-disclosure by the requester of the information; however, if this information is protected by the Federal Substance Abuse Confidentiality Regulations, the recipient may not re-disclose such information without my further written authorization unless otherwise provided for by state or federal law. I understand that if my record contains information relating to HIV infection, AIDS, or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing, this disclosure may include that information. I understand that I may request that the disclosure of this information be restricted. I also understand that I may refuse to sign this authorization. I also understand that the client and/or client guardian cannot deny or refuse to provide treatment or eligibility of benefits if I refuse to sign this authorization. (Note, however, if treatment is research related, treatment may be denied if authorization is not given.) I further understand that I will receive a copy of this signed authorization.

______

Signature of Client Date Witness and Date

______

Signature of Legal Guardian, Representative Date Relationship

AUTHORIZATION TO DISLOSE HEALTH INFORMATION - REVOCATION SECTION

I do herby request that this authorization to exchange/disclose health information of ______

Client's Name

Signed by: ______on ______Be rescinded, effective ______

Name of Person Who Signed AuthorizationDateDate effective

I understand that any action taken on this authorization prior to the rescinded date is legal and binding.

______

Signature of Client Date Witness and Date

______

Signature of Legal Guardian, Representative Date Relationship

TRAVEL/PHOTO AND ACTIVITY AUTHORIZATION

Blanket permission for this activity

Special 1 time permission only

Blanket permission for all given activities

I, ______parent/guardian of______give my

(Name of parent/guardian) (Name of Child)

permission to DREAMS AND VISION, LLC for my child to participate in the following activities:

Trips in the van/automobile (facility/parent/staff-owned)

______

Explain planned activity- where and when

Field trips away from the facility

______

Explain planned activity- where and when

I understand that the facility will use the appropriate child restraint devices and abide by all the safety rules in rule 1000 when my child is transported in a vehicle. The facility will also notify me each time my child is to participate in an activity that would involve transportation.

Parent/Guardian Signature ______Date ______

This authorization is valid from ______to ______

In addition, if the facility has planned activities out of the city/state

____ I will allow my child to participate

____ I will not allow my child to participate

Parent/Guardian Signature ______Date ______

Dreams and Vision, LLC

Application Agreement:

1. I (we) have received the Intake Packet for DREAMS AND VISION, LLC and understand the terms and conditions contained therein. YES______NO______

1. I (we) give consent for the above named client to receive DREAMS AND VISION, LLC and in doing so agree to abide by the terms as outlined in the Intake Packet.

AGREE______DISAGREE______N/A______

1. I (we) acknowledge that this service is voluntary and that I (we) may at any time discontinue this service. AGREE______DISAGREE______N/A______

1. I (we) agree to allow DREAMS AND VISIONS, LLC staff to implement accepted methods of therapeutic intervention as indicated by the client’s mutually agreed upon treatment goals/plan.

AGREE______DISAGREE______N/A______

1. I (we) have received a full explanation of the DREAMS AND VISION, LLC “Search and Seizure” procedure. I (we) agree to the use of this procedure in accordance with the manner prescribed.

AGREE______DISAGREE______N/A______

1. I (we) grant permission for this client to participate in DREAMS AND VISION, LLC outings with the knowledge that such will require being transported away from the facility. It is my (our) understanding that I (we) will be notified in advance of any overnight or out of state outing. I (we) agree not to hold DREAMS AND VISION, LLC liable in the event of an accident or injury.

Name: ______Date: __ /__ /__

AGREE______DISAGREE______N/A______

EXPLANATION: ______

______

______

1. I (we) authorize DREAMS AND VISION, LLC to transport this client to medical, dental, and mental health appointments at the services listed below, and to obtain treatment there for this consumer. I (we) agree to be responsible for charges that may be incurred from this service if otherwise not funded.

Treatment may include medication, specific diets, and specific medical procedure.

______

______

______

1. Stated religious preference for this consumer is ______. I (we) understand DREAMS AND VISION, LLC will respect this religious preference, and that this consumer will be permitted to attend services of this preference whenever feasible.

1. I (we) consent to information exchange between DREAMS AND VISION, LLC and the agencies for which we have signed release, but only to the extent necessary for the planning and implementation of individualized services for this consumer. I (we) understand that this information will include historical, psychological, medical, social, vocational, education, and behavioral data. The Confidentiality/Exchange/Release of Information Policy has been explained to me (us) and I (we) understand that consent is voluntary and may be revoked by me (us) at any time. I (we) understand that DREAMS AND VISION, LLC has policies protecting the confidentiality of this consumer.

1. I (we) understand under the following conditions that confidential information may be disclosed without consent:

• DREAMS AND VISION, LLC may disclose the fact of admission discharge of a consumer to the consumer’s next of kin whenever the responsible professional determines that the disclosure is in the best interest of the consumer, and
• A consumer may have access to confidential information in his consumer record, except for information that would injurious to the consumer’s physical or mental well-being, as determined by Director
• To certain consumer advocates
• To attorneys and in certain court proceedings
• When requesting by the Department of Corrections for an inmate
• A responsible professional may disclose confidential information when, in his opinion, there is imminent danger to the health or safety of the consumer or another individual or there is a likelihood of the commission of a felony or violent misdemeanor and
• A responsible professional may exchange confidential information with a physician or health care provider who is providing emergency services to a consumer to the extent necessary to meet the emergency need, and
• For certain statistical reporting and research

1. I (we) authorize DREAMS AND VISION, LLC to provide first aid assistance in the facility or during an outing.
2. I (we) understand that I (we) will be notified of any serious illness, any change in medical treatment or any medications administration to the consumer as a result of obtained medical care.

1. I (we) understand that prescription medication will be dispensed to this consumer only if the designated physician, ______, has ordered the said medication, provided staff with full instructions for administering the medication, and presented the medication to staff in a properly labeled prescription bottle.

1. I (we) agree to be responsible for purchasing and supplying medication for this consumer when in our care. I (we) agree to provide DREAMS AND VISION, LLC with a written medication order signed by the prescribing physician for each medication supplied to the program prior to placement.

1. I (we) agree to allow this consumer to be photographed and audio taped or videotaped, but only for treatment or training/supervision purposes and only for use by DREAMS AND VISION, LLC staff and members of the consumer’s Treatment Team. I (we) understand that photographing and audio taping or videotaping of this consumer for any purpose or audience other than those defined above shall require my (our) additional written consent. Finally, I (we) understand that confidentiality will be guaranteed in the use of this matter.

1. I (we) agree to allow this consumer to receive visits and telephone calls at the program from relatives and friends. Exceptions to people allowed to visit or call this consumer are listed below: (if no exceptions, please write “none”)

______

______

______

1. I (we) authorize DREAMS AND VISON, LLC to obtain emergency care for this consumer, if needed; until such time I (we) can be reached to authorize further care.

1. I (we) authorize DREAMS AND VISION, LLC to provide accurate educational information to this consumer regarding human sexuality, abstinence, contraception, and prevention of sexually transmitted diseases.

1. I (we) have been provided with a copy of the DREAMS AND VISION, LLC “Consumer Grievance Procedure” and I understand that the consumer and I may use the procedure to file a grievance if we are dissatisfied with the program services or feel that the consumer’s rights have been violated.

1. Exceptions and additions to consents: ______

______

______

1. I (we) understand that the responsibility for conduction family work with the consumer’s parents will be specified in the service plan. These responsibilities will include specifications for the responsible agency, the responsible professional, and frequency of interventions, location, and documentation.

1. All fees and plan for payment are the responsibility of the placing agency and NOT the consumer or consumer’s legal custodian unless otherwise specified by separate contract.

1. The projected length of stay, discharge date, and after-care plan will be developed during the Service Plan meetings. Service plan meetings and conferences will be held at least quarterly or as needed.

1. The consumer’s service plan will specifically document any specific conditions or restrictions for family time.

1. I (we) agree that this document may be amended on an as-needed basis, and that any such amendment will require the signature of the consumer’s parent and/or guardian.

1. I (we) understand that on this date a copy of the Admission Agreement, the Consumer Rights, and the Consumer Grievance Procedure will be made available to the consumer.

1. I (we) understand that consents will be reviewed and signed annually.

Dreams and Visions, LLC

Computer/Internet Consent

Consumer Name: ______DOB: ______

Medical Record #: ______Medicaid ID: ______

It is Dreams and Visions, LLC’s policy to allow consumers to utilize computers for school at the library under supervision of staff.

Guardian(s) give Dreams and Visions, LLC’s staff permission to allow this consumer to utilize the computer/internet and the following social networks:

_____ MySpace

_____ Facebook

_____ Twitter

_____ Oovoo

_____ Any other social networks

_____ Usage for school projects

_____ I do not give my child permission to utilize the computer/internet at any time.

By signing this form, Dreams and Visions, LLC’s staff will abide by your consent regarding the utilization of the computer/internet usage.

______

Consumer SignatureDate

______

Guardian SignatureDate

______

Dreams and Visions, LLC Staff SignatureDate

Dreams and Vision, LLC

CONSUMER’S PERSONAL FUNDS

12-16 Years

DREAMS AND VISION, LLC will manage personal funds of all consumers’ ages 12 to 16 years while in resident in this facility. All consumers funds that DREAMS AND VISION, LLC will manage in the group home will be kept separate from any operating funds belonging to the facility. Consumer’s funds will be stored separate in a safe, locked place. Each consumer will have her own personal container labeled with the consumer’s name, along with all receipts for expenditures. Each will have a register reflecting the same including balances. Staff will be responsible for the safekeeping, dispensing, and documentation of these consumer’s personal funds. Staff and consumers will sign the register for deposits, withdrawals and balances.