Life Springs Restoration Center

Streamlined admission packet | Linked fields reduce duplicate entry

Complete the client identifiers below once. They populate the chart-section headers and every matching field in the remaining packet.

In the fillable PDF, entering a repeated field once populates every occurrence with the same field name.

FILING ORDER: File only documents that apply to this client, the services delivered, and the payer. Within each category, place the most recent document on top.

Client identifiers entered on the checklist populate this header and every matching field throughout the packet.

SECTION I: INTAKE AND CLIENT PROFILE

Core intake, identity, consent, authorization and acknowledgment documents.

Client Intake Packet Checklist

Referral form / face sheet or documented referral source

Copy of Insurance Card

Copy of Photo Identification (parent/legal guardian identification when applicable)

Copy of Social Security Card (only when required by the payer or program)

Admission, Demographic, Contact, Health and Insurance Information

Emergency Contact / Emergency Fact Sheet

Provider Choice Statement

Informed Consent for Treatment

Financial Responsibility Agreement

Authorization for Use, Disclosure and Reciprocal Exchange of Information (copy as needed)

Acknowledgments and Consents (rights, privacy, grievance, faith-based, handbook, communication, transportation and 42 CFR

Part 2 when applicable)

No-Show and Cancellation Policy

Photography, Video, Testimonial and Marketing Authorization (optional)

Shared Faith-Community Relationship Acknowledgment (when applicable)

Telehealth Informed Consent (when applicable)

FILING ORDER: File only documents that apply to this client, the services delivered, and the payer. Within each category, place the most recent document on top.

Client identifiers entered on the checklist populate this header and every matching field throughout the packet.

SECTION II: ASSESSMENTS AND CLINICAL PLANNING

Assessment, risk, medical-necessity and individualized treatment-planning records.

Comprehensive Clinical Assessment / Diagnostic Assessment

Assessment Addenda, Updates and Reassessments

Diagnosis and ASAM Level-of-Care Determination (when a substance use disorder is present)

Risk, Suicide or Other Standardized Screening (when clinically indicated)

Safety Plan / Crisis Plan (when clinically indicated)

Individualized Treatment Plan / Person-Centered Plan

Treatment Plan Reviews, Updates and Revisions

Entrance, Continued-Service and Discharge Criteria Documentation

Service Order (when required for the clinician, service or payer)

Psychological or Psychiatric Evaluations (when completed or received)

Educational Records, IEPs, Behavioral Plans or External Clinical Histories (when relevant and authorized)

FILING ORDER: File only documents that apply to this client, the services delivered, and the payer. Within each category, place the most recent document on top.

Client identifiers entered on the checklist populate this header and every matching field throughout the packet.

SECTION III: SERVICE NOTES AND CLINICAL DOCUMENTATION

Notes and supporting records for services that were actually delivered.

Progress Note for Each Treatment Encounter - Individual, Family or Group

Telehealth, Telephonic or Collateral Contact Documentation (when used)

Crisis Intervention Note, Crisis Plan and Follow-Up Documentation (when provided)

Missed Appointment / No-Show Outreach Documentation

Clinical Note Addenda, Corrections and Late Entries

Required Supervisory Review or Co-Signature (when applicable)

Psychological Testing Service Notes and Reports (when provided)

Other Service Notes, Attendance Records or Logs (only for services actually provided)

FILING ORDER: File only documents that apply to this client, the services delivered, and the payer. Within each category, place the most recent document on top.

Client identifiers entered on the checklist populate this header and every matching field throughout the packet.

SECTION IV: CARE COORDINATION AND CORRESPONDENCE

Authorized communication and records exchanged to coordinate care and support continuity.

Care Coordination Request to Medical Provider and response

Behavioral Health Feedback to Primary Care Provider (when used)

Care Coordination and Case Consultation Notes

Primary Care / Medical Provider Records and Correspondence (when received)

School, IEP Team or Educational Correspondence (when relevant and authorized)

Hospital, Psychiatric or Inpatient Records (when received)

External Referral Documentation and Follow-Up

Client, Parent/Guardian or Authorized Representative Correspondence

Legal, Court, DSS or Probation Correspondence (when authorized)

Release-of-Information Updates, Restrictions or Revocations

Other Authorized Care-Coordination Correspondence (when received or created)

FILING ORDER: File only documents that apply to this client, the services delivered, and the payer. Within each category, place the most recent document on top.

Client identifiers entered on the checklist populate this header and every matching field throughout the packet.

SECTION V: ELIGIBILITY AND PAYER RECORDS

Eligibility and payer records, including authorization only when the service or payer requires it.

Insurance Eligibility Verification

Medicaid, Health Plan or Private Insurance Correspondence (when received)

Service Authorization / Prior Approval Request and Decision (only when required by the payer or service)

Authorization Extension, Change or Unit Tracking (only when applicable)

Utilization or Continued-Service Review Records (only when applicable)

Denial, Appeal, Reconsideration or Adverse Benefit Determination Records (when applicable)

NC-TOPPS Interview Records (only for publicly funded qualifying services and clients)

Payer Record Requests or Audit Correspondence (when received)

FILING NOTE: File authorization records only when the client's specific payer and service require them.

FILING ORDER: File only documents that apply to this client, the services delivered, and the payer. Within each category, place the most recent document on top.

Client identifiers entered on the checklist populate this header and every matching field throughout the packet.

SECTION VI: DISCHARGE, TRANSFER AND OTHER RECORDS

Records documenting transition, transfer, discharge, closure and items not assigned elsewhere.

Discharge / Transition Plan (when completed)

Discharge Criteria Documentation

Discharge Summary

Transfer, Referral, Closing Notification or Discharge Letter (when used)

No-Show or Loss-of-Contact Discharge Documentation (when applicable)

Post-Discharge Follow-Up Contact (when completed)

Final Assessment, Treatment Plan Review or Outcome Summary (when completed)

Records Received After Discharge or Closure (when received)

Miscellaneous Documents Not Clearly Assigned to Another Section

FILING NOTE: Use Miscellaneous only when a document does not clearly belong in Sections I-V.

SECTION 1 | ADMISSION AND DEMOGRAPHIC INFORMATION

Enter each data element once; later sections reuse linked fields.

ADMISSION AND REFERRAL

Admission date Referral date

Referral priority Referral source

Admission status Referral/contact phone

REQUESTED SERVICES

Comprehensive Clinical Assessment / Diagnostic Assessment Outpatient therapy

Peer Support Services Care coordination/referral

Telehealth modality - separate consent required Other authorized service

Other requested service

CLIENT DEMOGRAPHICS

Client legal name Preferred name

Date of birth SSN - last four only unless payer requires more

Sex Other - if selected

Marital status Veteran status

Select one Select one

Primary language Interpreter needed

Interpreter language/communication method Accessibility accommodation requested

CITIZENSHIP / IMMIGRATION STATUS - SELECT ONE

U.S. Citizen U.S. National Undocumented

RACE AND ETHNICITY - CHECK ALL THAT APPLY

African American/Black Asian/Micronesian Caucasian/White

Latino/Hispanic Native American/Alaskan Native Native Hawaiian/Pacific Islander

Other Other race/ethnicity - please explain

SECTION 2 | CONTACT, HOUSING AND SUPPORT INFORMATION

Housing language distinguishes general instability from current lack of housing.

CONTACT INFORMATION

Street/residential address Apartment/unit

City State

ZIP code County of residence

Mailing address - if different ZIP

Cell phone Alternate phone

Email Okay to leave voicemail

Current housing status Other/detail

Who does the client live with?

Housing-instability needs or barriers

PREFERRED COMMUNICATION

Cell phone call Text message Email

Client portal Mail Alternate phone

Communication restrictions or safe-contact instructions

ADDITIONAL CLINICAL AND COORDINATION CONTEXT

Primary reason for seeking services

Previous behavioral health providers

Current agency involvement or care team

SECTION 2 CONTINUED | EMPLOYMENT, CONTACTS AND

SUPPORTS

Support information is kept together and entered once.

EMPLOYMENT, EDUCATION AND HOUSEHOLD

Employment status Employer/occupation

Highest education completed School/training program

HOUSEHOLD INFORMATION

Number of individuals in household Currently pregnant

EMERGENCY CONTACTS

Primary emergency contact Relationship

Primary phone Alternate phone

Secondary emergency contact Relationship

Primary phone Alternate phone

PARENT, GUARDIAN OR LEGALLY RESPONSIBLE PERSON - IF APPLICABLE

Parent Guardian

Full custody Shared custody

Name Relationship

Phone Email

Address Other authority/detail

SECTION 3 | HEALTH AND INSURANCE

Clinical and payer details are collected once and reused.

PRIMARY CARE AND HEALTH INFORMATION

Primary care provider Practice

Phone Fax

Last physical examination Preferred hospital

Pharmacy name/phone Known allergies

Allergies/adverse reactions Important medical alerts

Medical diagnoses - if known Behavioral health diagnoses - if known Surgeries - if known

Current medications - name, dose, frequency and prescriber

SECTION 3 CONTINUED | INSURANCE, FINANCIAL AND

PRESENTING INFORMATION

INSURANCE - DO NOT REPEAT ELSEWHERE

Primary payer Member ID

Group number Subscriber name

Relationship to subscriber Co-pay/coinsurance

Authorization number Authorization dates/units

Secondary payer Member ID

Group number Subscriber/relationship

RESPONSIBLE PARTY AND ABILITY TO PAY

Financially responsible party Relationship

Phone Email

Monthly household income Number of dependents

CERTIFICATION

I certify that the information in Sections 1-3 is accurate and complete to the best of my knowledge. I will notify Life Springs

Restoration Center of material changes.

SIGNATURES

Client signature (type or sign) Date

Guardian/LRP signature (if applicable) Date

Staff signature / printed name / credentials Date

EMERGENCY CONTACT / EMERGENCY FACT SHEET

Internal emergency snapshot - information below autofills from Sections 2-3.

Staff: verify this page at admission and update it whenever emergency, medical or communication information changes.

CLIENT AND EMERGENCY CONTACTS

Client name Date of birth

Record number Date verified

Primary emergency contact Relationship

Phone Alternate phone

Secondary emergency contact Phone

EMERGENCY AND MEDICAL CONSIDERATIONS

Preferred hospital Pharmacy

Allergies/adverse reactions Important medical alerts

Mobility, sensory, safety or other emergency considerations

Primary language Interpreter/accommodation

Current medications - name, dose, frequency and prescriber (print-visible list)

PROVIDER CHOICE STATEMENT

Life Springs Restoration Center supports each client's right to make an informed and voluntary choice of qualified providers.

CLIENT ACKNOWLEDGMENT

SERVICES SELECTED

Comprehensive Clinical Assessment / Diagnostic Assessment Outpatient therapy

Peer Support Services Care coordination/referral

Telehealth modality Other authorized service

Other service

I voluntarily select Life Springs Restoration Center, 154/214 McIver Street, Sanford, NC 27330, for the service(s) identified above.

SIGNATURES

Client signature (type or sign) Date

Guardian/LRP signature (if applicable) Date

Staff signature / printed name / credentials Date

INFORMED CONSENT FOR TREATMENT

Applies to authorized Life Springs Restoration Center behavioral health services.

PROGRAM

After explanation of the requested service, expected benefits, material risks, available alternatives, program expectations,

confidentiality, client rights and crisis procedures, I voluntarily consent to receive the selected service(s).

Comprehensive Clinical Assessment / Diagnostic Assessment Outpatient therapy

Peer Support Services Care coordination/referral

Telehealth - separate consent also required Domestic Violence/Human Trafficking services

RIGHT TO CHOOSE PROVIDERS

I have the right to choose a qualified service provider. I may request a different Life Springs clinician, referral or transfer assistance, or help

identifying an outside qualified provider. My choice is voluntary, free from coercion, and will not result in retaliation or loss of rights.

IMPORTANT INFORMATION

Voluntary participation. I may ask questions, help plan services, refuse a recommended intervention, or withdraw consent in writing, subject to law

and safety requirements.

Benefits, risks and alternatives. Services may improve coping, recovery and stability, but outcomes are not guaranteed and difficult topics may

cause temporary discomfort. Alternatives include another provider or level of care, medication evaluation, community supports, or no treatment.

Confidentiality. Federal and North Carolina law protect my information. Disclosure without authorization occurs only when permitted or required,

including certain emergencies, safety concerns, abuse/neglect/exploitation reports, legal requirements, oversight, payment and operations.

Interventions and safety. Clinicians may use accepted, evidence-informed interventions consistent with my plan. Abusive, humiliating or

unauthorized restrictive practices are prohibited.

First aid and medication. Trained staff may assist with first aid. Outpatient and peer services do not administer medication but may coordinate

medication care or referrals.

Emergency response. When clinically necessary, staff may call emergency responders or arrange urgent evaluation while attempting to contact my

guardian/LRP or emergency contact.

Attendance and communication. I will participate consistently, give notice when I cannot attend, and keep contact and insurance information

current.

CONSENT TERM

Consent effective date Expiration date - not more than one year

I have read or received an understandable explanation of this consent, had an opportunity to ask questions, and received

satisfactory answers.

SIGNATURES

Client signature (type or sign) Date

Guardian/LRP signature (if applicable) Date

Staff signature / printed name / credentials Date

FINANCIAL RESPONSIBILITY AGREEMENT

Insurance and contact information autofill from Sections 1-3.

COVERAGE SUMMARY

Primary payer Member ID

AGENCY VERIFICATION - STAFF USE

Insurance card obtained Photo ID obtained

Eligibility verified Benefits verified

Authorization verified, if required Good-faith estimate/payment information provided, if

applicable

AGREEMENT

1. I am responsible for applicable co-payments, deductibles, coinsurance, self-pay charges and non-covered services, subject to payer

contracts, Medicaid rules and applicable law.

2. Insurance verification is not a guarantee of payment. I authorize Life Springs Restoration Center to submit claims and receive payment

for covered services, to the extent permitted by my plan and law.

3. I will promptly report changes in insurance, eligibility, address, phone number or financial responsibility.

4. Medicaid beneficiaries will not be charged a missed-appointment fee for Medicaid-covered services. Other fees, if any, follow written

agency policy, payer rules and applicable law.

5. If I have difficulty paying an amount owed, I may ask about an available payment arrangement or financial-assistance process.

ABILITY-TO-PAY INFORMATION - WHEN APPLICABLE

Can pay full applicable client responsibility Needs partial payment arrangement

Reports minimal/no ability to pay Self-pay

Approved arrangement/comments

SIGNATURES

Client signature (type or sign) Date

Guardian/LRP signature (if applicable) Date

AUTHORIZATION FOR USE, DISCLOSURE AND RECIPROCAL

EXCHANGE OF INFORMATION

Complete one authorization for each recipient/person/agency; copy this section as needed.

Signing is voluntary. Treatment is not conditioned on signing this authorization except when the requested service is solely for creating

information for a third party, as permitted by law.

CLIENT AND EXCHANGE PARTNER

Client name Date of birth

Record number Insurance/member ID

Person/agency Contact person

Address Phone

Fax Secure email

DIRECTION OF AUTHORIZATION

INFORMATION AUTHORIZED

All records described below, excluding psychotherapy notes

unless separately authorized

Assessments/evaluations Diagnosis and clinical summary

Treatment/service plan and goals Progress/coordination notes

Medication and allergy information Dates/types/providers of service

Discharge/transition summary Billing, eligibility and authorization information

Psychological/psychiatric evaluation Crisis/safety information

Substance use disorder records protected by 42 CFR Part 2, if

applicable

Other information - specify

AUTHORIZATION CONTINUED | TERMS AND SIGNATURE

DATE RANGE AND EXPIRATION

Records from Through

EXPIRATION

This authorization expires on If blank

PURPOSE

Treatment and care coordination Referral/continuity of care

Payment, eligibility or authorization Legal/administrative purpose specified below

At the client's request Other

Purpose detail

REQUIRED NOTICES

Revocation. I may revoke this authorization in writing at any time by delivering the revocation to Life Springs Restoration Center.

Revocation will not affect actions already taken in reliance on this authorization.

Redisclosure. Information disclosed to a recipient that is not governed by HIPAA or other privacy law may be redisclosed and may no longer

be protected by HIPAA.

42 CFR Part 2. If I authorize disclosure of records protected by 42 CFR Part 2, this authorization also serves as my written consent under 42

CFR 2.31 for the persons, information, recipients, purpose and expiration stated here. Part 2 records may not be used or disclosed in civil,

criminal, administrative or legislative proceedings against me except as permitted by written consent or court order.

Psychotherapy notes. Psychotherapy notes are not included unless a separate authorization specifically meeting applicable requirements is

completed.

Copy. I may request and receive a copy of this signed authorization.

I understand this authorization, it is voluntary, and the information, persons, purpose and expiration have been completed before I

sign.

Client/authorized representative signature Date

Printed name Representative authority - if applicable

Witness/staff signature Date

Copy provided/offered to client or authorized representative Authority/identity verified when signed by a representative

ACKNOWLEDGMENTS AND CONSENTS | PART 1

Receipt and understanding of rights, notices and agency information.

CLIENT RIGHTS SUMMARY

1. Be treated with dignity, respect, courtesy and freedom from abuse, neglect, exploitation, coercion, humiliation and retaliation.

2. Participate in person-centered planning; receive understandable information about services, benefits, risks and alternatives; ask

questions; and refuse treatment to the extent permitted by law.

3. Receive services from qualified staff in a safe, accessible and nondiscriminatory environment, with reasonable accommodation and

language assistance when needed.

4. Have privacy and confidentiality protected; receive the Notice of Privacy Practices; request access to records as permitted by law; and

receive information about disclosures.

5. Choose a qualified provider, request referral/transfer or discharge planning, and receive continuity-of-care assistance when clinically

appropriate.

6. Receive crisis and emergency information and file a complaint, grievance or appeal without retaliation.

A complete Client Rights Policy, grievance procedure and advocacy/contact information are available in the Client Handbook and upon

request.

I received or was offered the Client Rights information and had an opportunity to ask questions. Initials

RECEIPT OF NOTICES AND DOCUMENTS

Notice of Privacy Practices / confidentiality notice received or offered. Initials

Client Handbook received or offered. Initials

Grievance and complaint procedure received or explained. Initials

Crisis contacts and emergency procedures received or explained. Initials

FAITH-BASED ORGANIZATION ACKNOWLEDGMENT

Life Springs Restoration Center is a faith-based behavioral health organization guided by Christian values. Professional services are

provided with dignity, respect and without unlawful discrimination. Participation in prayer, spiritual discussion or any faith-based

activity is entirely voluntary, is not a condition of receiving services, and will not affect access to or quality of care.

I understand the faith-based nature of the organization and the voluntary nature of faith-based activities. Initials

EMERGENCY MEDICAL CONSENT

When clinically necessary, I authorize staff to call emergency responders and arrange emergency medical, dental, psychiatric or

behavioral health evaluation, transportation or stabilization while reasonable efforts are made to contact the legally responsible

person or emergency contact.

I understand and authorize the emergency response described above. Initials

ACKNOWLEDGMENTS AND CONSENTS | PART 2

Communication, transportation, Part 2 notice and acknowledgment of receipt.

COMMUNICATION CONSENT

I authorize service-related contact for scheduling, treatment, care coordination and billing through the methods I select. I

understand ordinary email/text may carry privacy risks and I may change or revoke these choices in writing.

Cell phone call Text message Email

Client portal Mail Alternate phone

Cell phone Email

Safe-contact restrictions Initials

TRANSPORTATION ACKNOWLEDGMENT

Transportation, when offered, is not guaranteed and depends on program eligibility, authorization, staff availability, safety and

agency policy.

I request transportation assistance when available. I do not need transportation assistance at this time.

I understand the transportation conditions above. Initials

42 CFR PART 2 ACKNOWLEDGMENT - WHEN APPLICABLE

Federal law provides additional protections for certain substance use disorder records. A separate written authorization/consent

may be needed for uses or disclosures not otherwise permitted. The current Notice of Privacy Practices explains applicable rights,

complaint options and restrictions on use of Part 2 records in proceedings against the client.

Not applicable to current services/records Applicable; information and rights were explained

I acknowledge the Part 2 information above when applicable. Initials

ACKNOWLEDGMENT OF RECEIPT

I received or was offered the documents and explanations identified in Parts 1-2, understand that I may ask questions or request

copies, and acknowledge that optional consents may be refused without loss of treatment eligibility.

SIGNATURES

Client signature (type or sign) Date

Guardian/LRP signature (if applicable) Date

Staff signature / printed name / credentials Date

NO-SHOW AND CANCELLATION POLICY

Consistent attendance supports progress and helps Life Springs offer timely access to other clients.

CANCELLATION AND MISSED APPOINTMENTS

Please provide at least 24 hours' notice when canceling or rescheduling, when possible. A missed appointment includes failure to

attend or a cancellation with less than 24 hours' notice.

Repeated missed appointments may lead to outreach, clinical review, same-day scheduling, reassessment of service needs,

modification of scheduling arrangements, or discharge when clinically appropriate and consistent with notice, continuity-of-care,

payer and legal requirements.

Medicaid beneficiaries are not charged a missed-appointment fee for Medicaid-covered services. Commercial-insurance or self-pay

fees, if any, follow the signed financial agreement, payer rules and applicable law.

CANCELLATION LIST - OPTIONAL

If an earlier appointment becomes available, staff may contact clients who volunteer for the cancellation list. Accepting or declining

an earlier time does not affect the original appointment.

Yes - add me to the cancellation list. No - do not contact me about earlier openings.

PREFERRED CANCELLATION-LIST CONTACT

Cell phone call Text message

Email Client portal

Contact restrictions

I received and understand the No-Show and Cancellation Policy.

SIGNATURES

Client signature (type or sign) Date

Guardian/LRP signature (if applicable) Date

Staff signature / printed name / credentials Date

PHOTOGRAPHY, VIDEO, TESTIMONIAL AND MARKETING

AUTHORIZATION

Optional - refusal will not affect services, supports or benefits.

Select NO or YES. If YES, select each permitted format and use. No authorization is assumed from an unanswered item.

AUTHORIZATION DECISION

AUTHORIZED FORMATS - COMPLETE ONLY IF YES

Photograph Video recording

Audio recording Written testimonial

Success story/interview First name only

Image without identifying name Image and first name together

AUTHORIZED USES - COMPLETE ONLY IF YES

Agency website Agency social media

Brochures/flyers/newsletters Community presentations/events

Educational/training materials Fundraising/public relations

Other authorized use

TERM AND NOTICES

Expiration date or event

I may revoke this authorization in writing. Revocation will not affect material already lawfully published, printed, distributed or

released before the agency receives the revocation. Protected clinical information, psychotherapy notes and Part 2 records are not

authorized by this form.

SIGNATURE

Client or authorized representative - signature, printed name and authority (if applicable) Date

SHARED FAITH-COMMUNITY RELATIONSHIP | PART 1

Client informed consent and boundaries acknowledgment for mental health and substance use disorder

services.

Complete this form when a client and a Life Springs workforce member share a church or faith community. It documents informed

choice, privacy protections and a clear boundary plan.

CLIENT AND RELATIONSHIP INFORMATION

Client name Date of birth

Record number Insurance/member ID

Clinician/staff name Date relationship identified

SERVICES INVOLVED

Mental health services Substance use disorder services

Peer support services Other service

Other service - specify

WHAT LIFE SPRINGS WILL DO

The workforce member will not tell church members, clergy, ministry leaders or others that the person is a client and will not discuss

treatment at church.

The workforce member will not initiate contact in a way that could reveal the treatment relationship. If the client initiates a greeting,

the response may be brief and social without confirming services.

Clinical discussions, scheduling, crisis concerns and records will be handled through approved Life Springs settings and communication

methods.

The client may request another qualified Life Springs clinician or assistance finding an outside provider, as available, without

punishment or different treatment.

Services do not depend on church attendance, religious participation, prayer, spiritual counseling or permission to contact a pastor or

church leader.

SHARED FAITH-COMMUNITY RELATIONSHIP | PART 2

Shared-community plan and client decision.

IMPORTANT LIMITS OF THIS FORM

CURRENT CHOICE

Boundary and church-encounter plan - greetings, shared activities, ministry roles, communication and limits

OPTIONAL SPIRITUAL INTEGRATION

SHARED FAITH-COMMUNITY RELATIONSHIP | PART 3

Acknowledgment and confirmation.

I had an opportunity to ask questions. I understand the shared-community relationship, foreseeable confidentiality and boundary risks,

available alternatives and the selected plan. I may request reassignment or report a concern at any time. This acknowledgment does not

authorize disclosure and does not waive any right.

Parent/guardian/representative name - if applicable Relationship/authority

SIGNATURES

Client signature Date

Parent/guardian/representative signature - if applicable Date

Clinician/staff signature Date

Clinical supervisor signature Date

TELEHEALTH INFORMED CONSENT | PART 1

Complete when telehealth will be used.

PURPOSE AND SERVICES

Telehealth uses secure electronic communication to provide clinically appropriate services when the client and practitioner are in

different locations.

Comprehensive Clinical Assessment / Diagnostic Assessment Individual/family/group outpatient therapy

Peer Support Services when authorized Care coordination/referral

Psychotherapy for crisis when clinically appropriate Other authorized telehealth service

BENEFITS, RISKS AND PRIVACY

Potential benefits include access, continuity, reduced travel and scheduling flexibility. Risks include technology failure, disrupted

communication, limited observation, delay, and loss of privacy if the client or practitioner is not in a private setting. Outcomes are

not guaranteed.

The confidentiality rules that apply to in-person services also apply to telehealth. Sessions will not be recorded by Life Springs

without separate written authorization. The client agrees not to record a session without the practitioner's prior written agreement.

TECHNOLOGY AND BACKUP CONTACT

Client phone Client email

Backup phone Private location/device available

If technology fails, the parties will attempt to reconnect. If reconnection is unsuccessful, the practitioner may call the backup

number and may reschedule or use another clinically appropriate method.

EMERGENCY PLANNING

Emergency contact phone Usual telehealth location

At the start of each telehealth session, the practitioner may verify the client's current physical location and emergency contact

information. Telehealth does not replace emergency services. In an emergency, call 911, contact the appropriate crisis service, or go

to the nearest emergency department.

TELEHEALTH INFORMED CONSENT | PART 2

Client choice, emergency authorization and signatures.

CLIENT RIGHTS AND CHOICE

I understand telehealth is voluntary. I may request in-person services when available and clinically

appropriate.

I may withdraw telehealth consent by notifying Life Springs. I had an opportunity to ask questions and received satisfactory

answers.

I will use a reasonably private location and protect access to

I authorize emergency contacts/responders to be contacted

my device/session. when clinically necessary.

SESSION-SPECIFIC LOCATION - STAFF VERIFIES EACH VISIT

Current physical location/address Session date

Client call-back number Staff initials

I voluntarily consent to telehealth services provided by Life Springs Restoration Center under the conditions described in Parts 1-2.

SIGNATURES

Client signature (type or sign) Date

Guardian/LRP signature (if applicable) Date

Staff signature / printed name / credentials Date

CARE COORDINATION REQUEST TO MEDICAL PROVIDER

Staff use only - send only when authorization or another lawful basis is documented.

This replaces the duplicate Behavioral Health Agency Request forms. Attach only the minimum information necessary, verify the

recipient before sending, and document the response/follow-up in the EHR.

CLIENT AND MEDICAL PROVIDER

Client name DOB

Record number Request date

Primary care provider Practice

Phone Fax

INFORMATION SENT WITH THIS REQUEST

Diagnosis/clinical summary Current medication/allergy list

Assessment summary Treatment plan/goals

Other minimum-necessary information No clinical attachment - request only

Other attachment/detail

INFORMATION REQUESTED FROM MEDICAL PROVIDER

Most recent physical examination Medical diagnoses/problem list

Current medication and allergy list Relevant recent lab results

Pain-management agreement, if applicable Other specific information

Other requested information

AUTHORIZATION AND SENDING RECORD

Authorization/lawful basis verified by Verification date

Requesting staff/provider Secure fax/email sent