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Outpatient - Opening Consents

Youth Legal Name:

Youth Preferred Name:

Youth Date of Birth:

Parent/Legal Guardian Name(s):

I have read and understood the information on the following explanations of the treatment services at Oregon Community Programs Outpatient Programs. I have had an opportunity to have my questions answered, and I have been offered copies for my records. I understand that the information referenced here is also available on the OCP website (oregoncommunityprograms.org).

Request for Alternative Communication

Email Communication

Opt OUT of email communication

Opt IN for email communication (provide email address(es).

Text Communication

Opt OUT of text communication - including appointment reminders

Opt IN for text communication - including appointment reminders (please provide phone number(s)

Video Telehealth Communications

Opt OUT of telehealth services

Opt IN to telehealth services (if applicable)

This Description and Consent to Services and Supports includes the following information:

Description of Services and Supports
Intensive In-Home Behavioral Health
Expected Outcomes, Benefits, and Possible Risks of Service
Release of Liability for Transportation and Community Activities
Confidentiality and Protected Health Information
Limits of Confidentiality
Consent to Telehealth
Authorization for Audiovisual Recording
General Fees
Fees charged for appearance at legal proceedings:
Rights
Grievances
Acknowledgement and Consent to Services

Description of Outpatient Services and Supports:

This document explains what to expect from services at Oregon Community Programs (OCP). If your questions are not answered in the following document, please feel free to ask the therapist you are working with or telephone OCP’s Outpatient Program Director, Evyan Daugherty, at: (541) 743-4340.

OCP is a non-profit treatment center dedicated to helping children and parents navigate challenges related to behavioral health. It is our mission to provide therapy and counseling services that have been proven through research to be effective for families.

Services and supports at OCP are typically informed by specific treatment models that have been proved to be effective, but they are also individualized to fit the needs of each child and family.

OCP emphasizes the critical importance of parents and caregivers to experiencing long-term improvements in mental health and family functioning. For that reason, we always ask for the parent or caregiver of minor clients to participate in services. In rare cases, a youth of at least 14 years of age may be able to receive services without parental or caregiver involvement, but in these cases we will work to include parents or caregivers into treatment before services are completed.

Parents/caregivers will be asked to participate in the development of your child’s individual services and support plan, sometimes called a treatment plan. You will be asked to provide information about your child and their family situation. Your child’s success in treatment is affected by your efforts, input, and honest sharing of the challenges and successes you have experienced. It is important for us that we work together as a team through the treatment process.

OCP offers a range of supports for our treatment programs, including therapists, skills trainers, peer support, family support, and other options. You and your family may meet with one primary therapist or with multiple OCP staff, depending on your needs. If you meet with multiple staff, you will be informed of who the lead therapist is, so you can direct questions or concerns about treatment to them.

For Intensive In-Home Behavioral Health Treatment (IIBHT) clients:

IIBHT is a short-term program designed to offer intensive services to qualifying families, in their preferred location, to stabilize behaviors and help youth maintain in their current placement. This may decrease the likelihood of referral to more restrictive settings or out of home placement.

If a client is approved for IIBHT, OCP assigns a Team Lead to coordinate IIBHT services and to be the primary point of contact for the child’s guardian. Team Leads work closely with the guardian and OCP clinical team to ensure timely and accurate support and updates to the child’s treatment, crisis, and safety plans. They utilize a variety of measures to track and assess outcomes with the goal of improving wellbeing and stability of the client and family. Families enrolled in IIBHT have 24/7/365 access to their Team Lead or an equivalent provider to support them in managing emotional and behavioral crises and in learning behavior management strategies to decrease the frequency of crises. Enrolled families are offered a minimum of 2 hours of services weekly. Services are individualized to a family’s needs and may include a combination of family therapy, individual therapy, skills training, youth and family peer support, case management, psychiatry, and telephonic or in-home proactive support and crisis response. Quarterly team meetings are scheduled and include members of the child’s broader team (e.g. school personnel, wraparound facilitators, natural supports, etc.)

On average, IIBHT services last between 3-6 months, after which program staff oversee the transition to an appropriate level of care. Transfer programs may include lower levels of care within OCP.

Expected Outcomes, Benefits, and Possible Risks of Service:

Benefits of treatment often include a reduction of challenging behaviors and conflict in the home, improved family communication, as well as increases in self-esteem, school performance, peer relationships, and coping skills. While we work hard to help our clients, we cannot guarantee success. If we determine that we cannot provide effective services and support, we will provide a referral to another mental health provider or behavioral health referral resource.

Risks can include behavior problems and emotional difficulties getting worse before they get better. Discussing certain issues and trying to change behaviors may be stressful, difficult, or time-consuming. We will be asking you to contribute information throughout treatment that will help to determine whether improvements are being made during the natural ups and downs of daily life.

There are also risks to not receiving services. Problem behaviors often do not change without treatment, and sometimes they get worse. Not treating problem behaviors or mental health symptoms can cause issues to become harder to treat over time or risk the development of other mental health or physical health symptoms, decreased quality of personal relationships, decreased quality of life issues, increased risk of victimization, accidents, substance use or self-harm or suicidal behavior, or other negative outcomes.

Release of Liability for Transportation and Community Activities:

OCP services regularly include community-based activities and recreation for youth to develop and practice those skills that they are working on in treatment. By signing this agreement, you acknowledge the inherent risks involved in such activities and consent to their child’s participation in such activities, including being transported by car by OCP staff. You also agree that OCP may seek emergency medical care for the client, if needed. Additionally, by signing this agreement, the guardian also agrees to hold harmless OCP for any injuries that may result by virtue of these activities. “Hold harmless” means that you cannot hold OCP legally responsible for risks involved in such activities, including any injuries or damages.

Confidentiality and Protected Health Information:

The information we obtain about you and your family is confidential, meaning it will not be released outside of our agency except in certain circumstances required by law. Those limits are discussed below. In general, if anyone other than you or a legal guardian asks us to discuss your child’s case, they will not be told anything unless you have signed a release giving permission to do so. After a release is signed, you have the right to cancel that permission at any time by submitting a request in writing to recordsrequest@oregoncp.org .

OCP staff on your treatment team may share information about your child’s treatment among our internal staff for the purposes of care coordination, scheduling, clinical supervision, quality improvement, or in other ways that support your child’s access to quality treatment. Our therapists sometimes participate in external consultation groups to improve their services. In those cases, the consultation group agrees to keep information confidential.

Additionally, OCP follows the rules of the federal Health Insurance Portability and Accountability Act (HIPAA). This means that information that is protected under this rule will not be shared unless you give written permission or the courts order it to be released. There are other aspects of HIPAA which are outlined in our Notice of Privacy Practices, which is available at our front desk or on our website at www.oregoncommunityprograms.org .You have a right to receive a copy of our Notice of Privacy Practices upon request. You have a right to request that some or all of your health information not be used or disclosed in the manner described by the Notice of Privacy Practices, but OCP is not required by law to agree to such requests.

To ensure confidentiality, all files and records pertaining to your child’s treatment documents are kept on a secure data server or a locked file.

Concerns related to protected health information may be directed to (541-743-4340) To the attention of: Yvonne Hubbard, HIPAA Privacy Officer Or Ana Day, Executive Director

Limits of Confidentiality:

There are certain circumstances where the law requires that specific information be shared, even without a release of information. Everyone at OCP is a mandated reporter. By law, we must report situations where a child or dependent adult is at risk of being seriously harmed or where a child or dependent adult is suspected of having been abused or neglected to the correct authorities.

If OCP staff believe a youth client may be at serious and imminent risk of a suicide attempt, we will disclose information to a parent, guardian, or other individual we believe can lessen the risk of a suicide attempt, including when a youth has consented to their own treatment.

There may be other individuals who have rights to access our records about your treatment, including but not limited to: officers of the court under subpoena or court order, non-custodial parents, or as required by law for an investigation of suspected child abuse.

OCP will also release information to insurance providers or the funder of treatment for the purposes of determining eligibility or receiving payment, including information about treatment, including diagnoses, sessions, and attendance. Health insurance providers, including Oregon Health Plan (OHP) and Coordinated Care Organizations (CCOs) may require that we provide them with information about your child’s diagnosis and treatment. Representatives from health insurance plans, including CCOs, will review files of enrolled clients for the purpose of utilization management, authorizing services, quality insurance, audits, and site reviews.

OCP may share your health information with other health providers when making a referral, providing coordination of care, or other situations noted in our Notice of Privacy Practices.

If client records are requested related to an investigation of professional licensing or credentialing, then these records may be released to the licensing or credentialing board without client consent under HIPAA regulations 45 CFR §164.512(d).

Consent to Telehealth:

By signing this agreement, the guardian acknowledges that they have the option to receive either in person or telehealth services. You agree to work with your clinical staff to identify the format that best meets your needs, including confirming readiness for telehealth sessions and access to a computer or mobile device. Participation in telehealth is voluntary, and you have the right to discontinue services by telehealth at any time, though doing so may mean changing therapists or clinical staff, changing appointment times, and/or choosing to pause services until in-person access is available. To participate in telehealth services, it may be needed to download security compliant videoconferencing software onto your personal phone, tablet, or computer. The risks associated with telehealth include disruption of services due to poor internet service or technology failures, interruptions from others in your environment that may disrupt privacy or confidentiality, and the staff working with you not being able to identify some risky situations. To reduce these risks, the clinical staff working with your child or family will make plans for how to manage these potential situations. By signing this consent, you also agree to follow guidelines for telehealth services including: being located in the state of Oregon, being in a safe location with few distractions, and informing your clinical staff if someone else is present. Further, you agree to inform the clinician of your physical location at each telehealth session.

Authorization for Audiovisual Recording:

Our lobby, hallways, and most rooms where therapy or childcare services are offered are equipped for continuous audiovisual recording. Audiovisual recording of sessions helps OCP clinical staff provide the highest quality services. We typically record treatment sessions for the purpose of case supervision and coordination. At any time, you may request that videos made of you and your family members be erased, and we will do so. Access to video recordings of sessions is limited to certain staff as outlined in our Audiovisual Policy, including retention policies.

By signing this agreement, you authorize OCP to use any audiovisual recording made of you and your family for internal supervision, internal training and internal case coordination. Upon written notice, you may have all the audiovisual recordings erased and/or restrict their use. Any audiovisual recording will be destroyed after its use has been complete. Recordings are never considered part of the clinical record. Clients may revoke or restrict authorization for videos to be used for training or any other purpose at any time by alerting their lead therapist or a Program Director.

Because OCP trains our therapists to deliver specific, high-quality interventions, there are some limited circumstances where we may request your separate written permission for some video recordings to be reviewed by clinical trainers outside of OCP. You will have a separate opportunity to approve or decline use of your video recordings in this way. However, because video review is required for some interventions, declining may mean that you cannot receive that particular service. In that case, we will work with you to identify another treatment option at OCP that meets your needs or refer you to another provider.

General Fees:

OCP services are funded through several sources, including Oregon Health Plan (OHP), private insurance, private pay, or contracts with state or county programs. To increase access in our community, OCP may offer a sliding scale for some private pay services. Clients with valid OHP coverage will receive treatment in accordance with OHP coverage standards, which is typically free of charge.

OCP is an out-of-network provider for most private insurance companies, and we will collect co-pays and payment for private insurance non-contracted services at the time of service.

If you have both OHP and private health insurance, we are required to bill your private health insurance company prior to billing OHP.

OCP will charge a fee to the issuer of a subpoena and for records requests, as allowable by law.

Fees charged for appearance at legal proceedings:

By signing this agreement, you acknowledge that OCP staff do not make recommendations about parental fitness, custody arrangement or similar requests, as OCP's relationship with clients and families is therapeutic, not evaluative.

Compensation for the required time away from clinical practice is required and is usual and customary when professionals are requested to participate in legal proceedings. Regardless of the length of court-related attendance, any appearance requires the cancellation of client appointments for the day as well as preparation time and travel expenses.

By signing this agreement, you agree to pay a fee for in person or virtual court appearances or depositions required by subpoena issued by you or your legal representation to an OCP staff member. Our appearance fee of $1,000 per day is based on the cost of disruption to client services and staff schedules. This fee is applied when an OCP staff person is summoned by subpoena to appear in person or remotely at a legal proceeding or deposition, even if they do not actually testify. Because court appearances can vary in length and require cancellation of sessions for other clients, this fee is not prorated for partial day appearances. Multiple day subpoenas will incur the fee for each day the staff person is summoned. If multiple OCP staff members are summoned by subpoena, the fee is applied to each staff person for each day summoned.

Because OCP is prohibited from sharing confidential or privileged information without valid written authorization or court order, the OCP staff member may decline to provide information protected by confidentiality laws, even if the appearance fee is paid. Additionally, payment of the appearance fee does not guarantee that information offered is favorable to the client or guardian.

Rights:

All children and families who participate in services at OCP funded by OHP have rights in accordance with OAR 309-019-0115. These rights are published in full on our website at www.oregoncommunityprograms.org , but they generally include:

The right to privacy protection and confidentiality
The right to be treated with dignity and respect
The right to not be discriminated against for race, color, creed, religion, or sexual orientation.
The right to be provided with information about participating in services, including information in their clinical record upon request
The right to be involved in the development of their service and support plans
The right to have information regarding the potential risks and benefits of service
The right to be free from seclusion and restraint.
The right to refuse service at any time
The right for foster youth to access their attorney, caseworker, or CASA
The right to file a verbal complaint or written grievance.

For children and families participating in OCP services, including but not limited to Parent Child Interaction Therapy (PCIT) and GenerationPMTO, a component of the treatment includes incorporating developmentally appropriate limits, including time out. Use of time out in alignment with these best practices is not considered seclusion or restraint.

For clients age 18 or older: The OCP website also includes opportunities to register to vote and to complete a Declaration for Mental Health Treatment.

Grievances:

We encourage you to be active participants in your own treatment and to first address concerns, questions, or potential issues with the clinical team member working most directly with you. If needed, you may also speak with their supervisor. You have the right to make a verbal or written complaint without fear of retaliation or negative impact on treatment services.

We hope that most issues can be worked out directly with your therapist and/or supervisor, however, if the issue is not resolved at that level, you may submit a grievance form. Grievance forms are available on our website or from our front desk. You may also contact our Executive Director or Program Director at (541) 743-4340 to initiate the grievance process verbally.

The steps to file a grievance are:

Complete the grievance form and submit it to OCP staff, including our front desk. An oral request to file a grievance can be sufficient. Grievances may also be submitted directly through our website.
Grievances will be received and reviewed by the Executive Director. The Executive Director, Clinical Director, or Outpatient Program Director may offer to meet with the individual or family submitting the grievance.
A written response to the grievance will be provided by secure email or USPS to last known address on file within 30 calendar days from the date of OCP’s receipt of the grievance.
The response will include the next steps that may apply to the situation, including the appeal process.

Appeals must be submitted in writing to the Health Systems Division within 10 business days of the Executive Director’s response to the person initiating the grievance. OCP staff will make available the forms needed to submit such an appeal and can help the individual or family complete the appeal upon request.

If the nature of the grievance is time sensitive, then the individual or guardian of the individual, may request an expedited review. The Executive Director or designate will review and respond in writing to the grievance within 48 hours of receipt of the grievance.

If you wish to speak to someone outside of OCP, you may contact your health insurance plan, CCO, or one of the following resources:

Trillium Community Health Plan, Member Services: (800) 910-3906
PacificSource Community Solutions, Customer Service: (800) 431-4135
Umpqua Health Alliance, Customer Care: (866) 672-1551
Yamhill Community Care: (855) 722-8205
Oregon Health Authority Ombudsperson: (877) 642-0450
The Governor’s Advocacy Office: (541) 945-6904
Disability Rights Oregon: (800) 452-1694

Acknowledgement & Informed Consent to Services & Support:

I, as parent or guardian, by signing below indicate that:

-- I have had the opportunity to read and ask questions about all the information listed in this document.

-- I willingly consent to participate in the program.

-- I understand that information gathered about my child and my family will be kept confidential with the exceptions listed above.

-- I understand the risks and benefits of services and support.

-- I understand that I have the right to withdraw from services.

-- I understand I may file a grievance without retaliation. I have been informed of and understand the grievance process.

-- I have been informed of my rights

-- I understand that if my child is covered by OHP, my file will periodically be reviewed by my assigned CCO), Oregon Health Authority and the OCP Performance Quality Improvement Committee.

-- I understand I can request a copy of the Notice of Privacy Practices.

-- I have been offered or received a copy of this document which includes: Description of Services and Supports, Intensive In-Home Behavioral Health, Expected Outcomes, Benefits, and Possible Risks of Service, Release of Liability for Transportation and Community Activities, Confidentiality and Protected Health Information, Limits of Confidentiality, Consent to Telehealth, Authorization for Audiovisual Recording, General Fees, Fees charged for appearance at legal proceedings, Rights, Grievances, and Request for Alternative Communication.

By signing this agreement, I consent to services and treatment from Oregon Community Programs:

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February 5, 2021 11:28 am PDT

Outpatient - Opening Consents Uploaded by Caley Rea - caleyr@oregoncp.org IP 10.0.10.128

February 5, 2021 1:07 pm PDT