Therapy Service Intake Form

Chapter 415, Florida Statutes, charges the Department of Children and Families with providing comprehensive protective services for abused or neglected children found in the state, and requires that reports of each abused or neglected child be made to the Florida Abuse Hotline. The statute also charges the Department with providing social services to detect and correct abuse, neglect, and exploitation of elderly persons and disabled adults who, because of their age or disability, may be unable to adequately provide for their own care or protection.

Your DSA Therapy & Health Services representative has explained to you, in your language of choice, the following:

• How to recognize physical, behavioral, and environmental indicators of child/adult abuse, neglect, and exploitation.
• How to report suspected abuse to the Florida Abuse Hotline: 1-800-962-2873 (1-800-96-ABUSE) — report verbal abuse, hitting, marks and bruises, not receiving food, medications or clothes, or not feeling safe. Provide name, address, phone number, and the type of abuse.
• How to report life-threatening emergencies to 911 — fire, injuries, accidents, and any violence. Provide name, address, phone number, and the nature of the emergency.

DSA Therapy & Health Services representatives have furnished you with the numbers to report suspected abuse as well as life-threatening emergencies.

Our Notice of Privacy Practices (NPP) describes in detail how this organization may use and disclose your Protected Health Information (PHI) for purposes permitted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations. You have the right to review the NPP before signing this acknowledgment and consent.

The NPP may be amended periodically to reflect changes in applicable laws or organizational policies. Should the NPP be revised, an updated version will be made available to you within two business days of the effective date of the revision.

You have the right to request restrictions on the use or disclosure of your PHI for treatment, payment, or health care operations. While the organization is not obligated to agree to every requested restriction, any restriction that is formally accepted will be honored unless disclosure is otherwise required or permitted by law.

By signing this document, you acknowledge receipt of the NPP and provide consent for the use and disclosure of your PHI for treatment, payment, and health care operations as outlined in the notice.

You retain the right to revoke this consent at any time, provided the revocation is submitted in writing. Revocation will not apply to any actions already taken in reliance on your prior consent or to disclosures that are permitted or required by law. Assistance in preparing a written revocation will be made available upon request.

Chapter 393 of the Florida Statutes says that you have the right to:

• Dignity, privacy, and humane care.
• Religious freedom.
• Services that protect personal liberty and provide the least restrictive environment to achieve treatment outcomes.
• An appropriate quality education and training service.
• Social interaction and participation in community activities.
• Physical exercise and recreational opportunities.
• Freedom from physical harm, abuse, neglect, and physical and chemical restraints.
• Give consent or refuse treatment.
• Not to be discriminated against because of your developmental disability.
• Vote.

I have received a copy of my rights and had the opportunity to discuss them with a representative of DSA Therapy & Health Services.

Written grievance policies and procedures will be used to resolve conflicts that may arise between the consumer, family and/or guardian and the provider. These procedures do not preclude appropriate requests for a hearing in accordance with Chapter 120, F.S., nor do they preempt the consumer, family, and guardian's right to request a change in service and/or request a meeting to discuss other issues of concern.

The consumer initiating the complaint will complete the grievance form. If the consumer cannot write, the verbal complaint will be written for the individual by direct care staff, the consumer's social worker, friend, or other advocate. The grievance form will contain the name of the consumer initiating the complaint, the date the complaint was received, and a clear description of the complaint.

All complaints will be retained in the consumer file with a copy contained in the grievance log, maintained in the office of Dickens Sanomi Corp / DSA Therapy & Health Services. Upon notification of a grievance, the owner will investigate the facts and issues and attempt to resolve the grievance; unresolved grievances will be directed to the consumer's social worker as the next step of resolution.

Response to the grievance will be provided verbally and in writing on the grievance form within 7 days of the complaint being received.

I understand that by signing, I am giving consent to Dickens Sanomi Corp / DSA Therapy & Health Services to implement the treatment procedure specified herein. I am giving my consent of free will and accordingly without coercion. The risks and benefits of the procedure(s) have been clearly stated, and I understand them completely. I also understand that I have the right to refuse to give consent without penalty or to retract consent at any time and exercise my rights and choices. I agree as well that the implementation of the service plan will be ongoing to monitor progress with goals specifically outlined in the client's service plan. By signing below, services for Targeted Case Management will begin.

Consents are valid for one (1) year from the date signed.

DSA Therapy and Health Services provides psychological evaluations for students who exhibit a need. A psychological evaluation is a comprehensive assessment that helps mental health professionals determine a person's mental health status and identify any potential issues that may interfere with their emotional, behavioral, and cognitive well-being. Our in-house school psychologist administers evaluations throughout the school year.

As the parent/guardian of the child named in this packet, I give DSA Therapy and Health Services consent to administer a psychological evaluation to my child, and I give Dickens Sanomi Academy consent to monitor my child's mental health and well-being. I understand that psychological evaluation reports, summaries, or other related documents will be released to me only after all applicable fees for the evaluation have been paid in full.

Federal law, including the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. §1232g, protects the confidentiality of student education records. To comply with FERPA, Medicaid program requirements, and applicable federal and Florida laws, written parental consent must be obtained before personally identifiable information from a student's education records is disclosed for Medicaid billing, reimbursement, program administration, auditing, or other authorized Medicaid activities.

I understand that my child may receive health-related services through the school's Medicaid School-Based Services Program, and I authorize Dickens Sanomi Corp / DSA Therapy & Health Services to release information from my child's education records as permitted under FERPA and applicable state and federal laws. Information disclosed may include student name, date of birth, Medicaid identification number, service dates, type of services received, provider information, and documentation necessary to support Medicaid claims.

The purpose of this disclosure is solely to determine Medicaid eligibility; submit, process, and receive Medicaid reimbursement for covered services; and support Medicaid program administration, audits, and compliance activities.

Granting consent is voluntary. Refusing consent will not affect your child's right to receive educational or medically necessary services. Consent remains effective until revoked in writing; revocation will not affect disclosures already made. The school/provider may not disclose information beyond what is necessary for Medicaid-related purposes unless otherwise permitted by law.

The undersigned permits Dickens Sanomi Corp / DSA Therapy & Health Services to release, exchange, or request information on the above-named client, including but not limited to medical, psychological, psychiatric, and substance abuse records, from the identified requester. By my signature, I authorize the release of such information while acknowledging that it may be protected by one or more chapters of Florida statute and federal law. This information would not be accessible to the requester without the consent in this document. The information may not be further disclosed without specific authorization by the consumer or his/her guardian representative. A reproduction of this authorization shall have the same effect as the original.

Provider: Dickens Sanomi Corp / DSA Therapy & Health Services · 3020 NW 33rd Avenue, Lauderdale Lakes, FL 33311 · Phone (954) 306-3914 · Fax (855) 717-2422

I hereby assign applicable Medicaid benefits and payment directly to Dickens Sanomi Academy for therapeutic services rendered by Dickens Sanomi Academy.