Chosen Care Application

This form will take approximately less than 10 minutes to complete.

Chosen Care, Inc. Client Release of Liability

Chosen Care Overview Services Available:

• Caregiver Coaching
• Caregiver Education
• Counseling
• Targeted Case Management
• Peer Support
• Therapeutic Referral

Hours:
Normal office hours are Monday – Friday; 8:00a – 5:00p.
Accommodations outside of these hours may be made if needed.
Fees are calculated based on a sliding scale of income and family size. Service fees will be discussed following application submission and two complimentary sessions.
Behavior Support Management Policy Chosen Care does not use restrictive behavior management interventions and are not authorized to use it. We promote respect, healing, and positive behavior of the client and prevent the need for crisis interventions. Further, Chosen Care monitors potential harassment or violence towards others, including other service recipients or personnel, and utilizes the below levels to mediate any circumstances.
Chosen staff is trained in the Trauma Competent Caregiver Curriculum by Back2Back Ministries as well as Trust-Based Relational Intervention (TBRI ®) developed by Dr. Karyn Purvis and David Cross at the TCU Institute of Child Development which utilize TBRI® Levels of Response™. The level system is used to de-escalate situations.
Level 1: Playful Engagement
Level 2: Structured Engagement
Level 3: Calming Engagement
Level 4: Protective Engagement

Chosen Care advises clients to seek formal training during Level 4 Response. This would come from the agency through which the child was placed in their home.
The organization does not escort individuals or use seclusion. The organization does not use locked seclusion. The organization is not qualified to authorize a restrictive intervention. Personnel will not be involved in any restrictive behavior management interventions while in the home. If staff is a witness to the incident, they will debrief with client to identify possible injuries and emotional reactions. The organization is not responsible for incidents and advise clients to report to their agency immediately.
If a client discloses information about using a restrictive behavior management intervention, Chosen Care staff will document it in clients file including the justification, use, circumstances, and length of application. All attempts made prior to use of the restrictive behavior management intervention will also be identified and documented.
Staff will review the incident and talk through de-escalation strategies for future scenarios. The organization supports the safest environment possible and wants to further reduce the use of restrictive interventions.
Chosen Care, Inc. Client Privacy Rights and Responsibilities Service Delivery Services are generally delivered through various forms of technology, included but not limited to Zoom meetings, phone calls, emails, and more. When technology-based services are unavailable to clients, location of meetings will be determined with your assigned Care Manager.
Chosen Care’s staff respects the privacy of clients in every manner of service delivery. Employees demonstrate competency in the security and general resources of any technological service used before leading client services. Employees monitor confidentiality issues and other areas of concern, ensuring that clients are consistently protected.
Responsibilities Clients are responsible for various expectations during services with Chosen Care, Inc. Clients understand that services are provided during the hours of 8:00a-5:00p CST, and any requests for services provided at other times may be declined. Clients are also expected to provide proper notice, per the agreements signed at intake, for any changes in information, client status, or need for services.
Legal Duties State and Federal laws require that we keep your health records private. Such laws require that we provide you with this notice informing you of our privacy of information policies, your rights, and our duties. We are required to abide these policies until replaced or revised. We have the right to revise our privacy policies for all medical records, including records kept before policy changes were made. Any changes in this notice will be made available upon request before changes take place. The contents of material disclosed to us in an evaluation, intake, or counseling session are covered by the law as private information. We abide by ethical and legal requirements of confidentiality and privacy of records.
Use of Information Information about you may be used by the personnel associated with this organization for diagnosis, treatment planning, treatment, and continuity of care. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian or personal representative. We may ask for permission to disclose information to health care providers who provide you with treatment, such as doctors, nurses, mental health professionals, and mental health students and mental health professionals or business associates affiliated with this clinic such as billing, quality enhancement, training, audits, and accreditation. It is the client’s responsibility to provide necessary information for services to be provided as accurately and effectively as possible. It is the policy of this organization not to release any information about a client without a signed release of information except in certain emergency situations or exceptions in which client information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.
Duty to Warn and Protect When a client discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
Public Safety Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws.
Abuse If a client states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child (or vulnerable adult) is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a client is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, we may share this information with law enforcement officials.
In the Event of a Client’s Death In the event of a client’s death, the spouse or parents of a deceased client has a right to access his/her child’s or spouse’s records, upon request.
Professional Misconduct Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.
Judicial or Administrative Proceedings Health care professionals are required to release records of clients when a court order has been placed.
Other Provisions When payment for services are the responsibility of the client, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed.
Insurance companies, managed care, and other third-party payers are given information that they request regarding services to the client. Information which may be requested to include type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, and summaries. Redacted information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. Progress notes and reports are dictated/typed within the clinic or by outside sources specializing in (and held accountable for) such procedures. In the event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please notify us in writing where we may reach you by phone and how you would like us to identify ourselves. If this information is not provided to us (below), we will adhere to the following procedure when making phone calls: first we will ask to speak to the client without identifying the name of the agency. If the person answering the phone asks for more identifying information, we will say that it is a personal call. We will not identify the agency. If we reach an answering machine or voice mail, we will follow the same guidelines.
Case Record Rights You have the right to request to review or receive your health files. The procedures for obtaining a copy of your information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. You have the right to cancel a release of information by providing us a written notice. If you desire to have your information sent to a location different than our address on file, you must provide this information in writing. You have the right to restrict which information might be disclosed to others. You have the right to request that information about you be communicated by other means or to another location. This request must be made to us in writing. You have the right to disagree with the records in our files. You may request that this information be changed. Although we might deny changing the record, you have the right to make a statement of disagreement, which will be placed in your file. You have the right to know what information in your record has been provided to whom. Request this in writing. If you desire a written copy of this notice you may obtain it by requesting, it from the Program Director of Chosen.
Self-Determination Rights All clients have the right to provide feedback and input into service delivery and service content. All services received will be non-coercive to allow clients the ability to self-determine their needs with the guidance of their Care Manager. Any decisions made regarding treatment will include the input and acceptance of clients. Clients have the choice to consent to services and be informed of benefits, risks, and alternatives to planned services. Clients have the right to refuse any service.
Fair and Equitable Treatment All clients have the right to fair and equitable treatment in a non-discriminatory manner. Chosen Care, Inc. does not discriminate based on gender, age, religion, ethnicity, culture, language, sexual preference or any other factors. Chosen Care, Inc. agrees to provide all services consistently and respectfully in accordance with company policy and expectations.
Complaints If you have any complaints or questions regarding these procedures, please contact the Chosen. We will respond in a timely manner. You may also submit a complaint to the U.S. Dept. of Health and Human Services. If you file a complaint, Chosen will not retaliate in any way. The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the “medical records privacy law,” HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“security rules”). HIPAA requires providers and health care agencies throughout the country to provide patients a notification of their privacy rights as it relates to their records. You may have already received similar notices such as this one from your other health care providers. This Patient Notification of Privacy Rights is our attempt to inform you of your rights. Please read this document, as it is important you know what patient protections HIPAA affords all of us. If you have any questions about any of the matters discussed in this document, please do not hesitate to ask for further clarification. Please understand that you are responsible for your own understanding of these regulations and rights.
Release for Telehealth Services: By signing this release, I am granting permission to receive Chosen's services with Telehealth, which includes using a secure online video platform or phone calls instead of meeting in person when circumstances are appropriate for doing so. Please know that sometimes there are technology issues that can prove challenging, and there is a slight risk that someone who isn't supposed to listen to our call or meeting could listen in. My signature acknowledges this risk.

Authorization

I have read the above information and wish to partake in Chosen Services with my assigned Care Manager.
I understand that I have no financial obligation to Chosen Care for the initial two complimentary sessions.
I understand that there is no obligation to continue services past these two sessions.
I understand that my information will be kept on file during and after my services are complete.
Digitally signed by *
On *
URL
URL

Verification

Please enter any two digits *Example: 12
This box is for spam protection - please leave it blank:

Client Payment

Registered 501(c)(3). EIN: 81-2872095