I hereby authorize the Powerhouse Community Development Corp. to release and obtain personal information for the purpose of assisting me with obtaining program support services, employment, continuing education goals, and communications with referring agencies. I understand this information will only be used to ensure quality services. No information obtained will be released without my expressed permission.

I hereby declare that the above information is complete and accurate to the best of my knowledge and I can be held responsible for any inaccuracies later.

PURPOSE OF DISCLOSURE:

• To maintain communication with referring agency        

• Referrals for wrap-around services

• To assist in my program development        

• Program recommendations

• To assure coordination of care    

• Other; specify attendence, participation, progress, A& D tests, 

INFORMATION TO BE DISCLOSED:

• Intake Information

• Assessments

• Acknowledgment of status as a client    

• Employment status

• Program plan and/or Reviews      

• Progress Notes

I understand that my records are confidential and by signing this authorization, I am allowing the release of my personal information. This may include information about my substance abuse, medical and mental/behavioral health information. Alcohol and drug abuse information (as part of a alcohol/drug abuse program) is specifically protected by HIPAA and federal regulations 42 CFR Part 2. By signing this authorization without restrictions, I am allowing the release of any program records, alcohol and/or drug information records, medical and mental health records to the agency or person specified above.

My signature below acknowledges that I have been informed of confidentiality, and that I understand and authorize the release of my protected health information. I understand that I have the right to revoke this authorization in writing at any time the facility that I am receiving service. I acknowledge receipt of a copy of this authorization.

*Disclosure is effective on today's date and expires one year later*

 

 

I understand that my records are confidential, andthat by signing this authorization I am allowingthe release of my personalinformation. This may include information about mysubstance abuse, medical and mental/behavioral healthinformation.Alcohol and drug abuse information (as part of a drugand alcohol abuse program) is protected by HIPAAand federalregulation 42 CFR Part 2. By signing this authorizationwithout restrictions, I am allowing the release ofany alcohol and druginformation records, medical, and mental health recordsto the agency and/or person specified above.

 

My signature below indicates that I have been informedof confidentiality, and that I understand and authorizethe release of myprotected health information. I understand that Ihave the right to revoke this authorization in writingat any time at the facilitythat I am receiving services. I acknowledge receiptof a copy of this authorizatio

Recovery Support Contract

Intake:    Assessments are conducted by certified staffand approved by the Department of Mental Health.

Orientation:    Client is briefed on the minimum  expectations of attendance, as well as the results of non-compliance.

Level of Care: Phase 1 Phase one will consist of 24 sessions of Life Skills, Conflict Resolution, Fatherhood, Parenting, and Substance Use classes. As well as GED orEducation support, as required, and Power ofHOPE.

 Phase 2   Phase two will consist of a minimum of 8 sessions of one-on-one services in order to help client complete his or her transition back into some form of sustainable, substance free lifestyle.

 Client will be required to complete combined group and individual sessions. Client will also work toward achieving program goals. Once both criteria are satisfied the program will be considered successfullycompleted.

We believe that our clients should have certain tools and resources to transition into recovery, be in recovery, and remain in recovery.

There is a minimal expectation of attendance, involvement, and participation from each of our clients.

We will work closely with you and other agencies to help accommodate your schedule; however repeated absences or unexcused absences will result in a non-compliance report being sent to Probation and Parole or other designated agencies.

PCDC is committed to helping you receive an array of wrap-around services, designed to engage, equip, and empower you on your journey to new beginnings.

If you understand PCDC’s commitment to your well-being and are ready to begin your journey, please sign below.

The above information will be used for the following purposes:
I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45
(Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the
recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.
I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent
automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this
authorization. I understand that I have a right to refuse to sign this authorization.
If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

By signing this you are giving me permission to determine how we can best help you based on your eligibility and appropriateness for our services. If you are eligible for recovery support services, we will issue vouchers to the agency of your choice to be reimbursed for their services. By signing this you are also giving me permission to issue those vouchers if a determination is made to continue with the rest of the intake and assessment process to enroll you in services.

Privacy of Individually Identifiable Health Information, Parts ·150 and ·164) and Title 45
(Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules. I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization. If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.