New Client Intake

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4348 Jeffrey Dr.

Baton Rouge, LA 70816

225-361-0219

Instructions:

Before filling out the Intake form, Please click on the "Forms to read" (If you have not received a copy of these documents already).
Once read, you will be required to initial different sections to comply with these documents and sign electronically. (This form will remain open in order for you to return back to it after reading the documents)

Once the form is completed hit the "Preview" button. Go over the form to make sure everything is filled out, then hit the "Register" button at the bottom of the form.

Forms To Read

Patient Name Below

Name

DOB:

YYYY

AGE

Sex:

Race:

Marital Status:

Ethnicity:

Medicaid Number: (to be filled out when you arrive at the facility) _____________________________

Soc. Sec. Number: (to be filled out when you arrive at the facility) _____________________________

Guardian Name:

Relationship:

CONTACT INFORMATION:

Phone Number:

Alternate Phone Number:

Address (no P.O. box):

City:

State:

Zip:

Mailing Address:(If different)

EDUCATION:

Is the client enrolled in school?

Yes

SCHOOL NAME:

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PRESENTING PROBLEM (S): Please check all that applies

Anxiety

Criminal behavior(stealing, breaking into houses and vandalism)

Constant restlessness

Cutting Self

Defiance (not wanting to do what they are told)

Depression

Destructiveness (e.g., destroying property)

Difficulty concentrating

Fidgety

Fighting

Fire-setting

Forgetting instructions

Hitting or biting themselves

Hurting pets or other animals

Low self-esteem

Lying

Phobias

Running away

Suicidal

Talking back or arguing with parents/teachers

PAST TREATMENT:

Has the client been diagnosed with a behavioral or mental disorder in the past?

If “Yes”, what was it?

Was the client prescribed any medication for this diagnosis?

If “yes” what kind?

Has the client ever been enrolled in another agency/program?

Yes

If “yes” where?

Referral Source:

Assessment Appointment Date:

YYYY

Assessment Appointment Time:

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AUTHORIZATION FOR SCHOOL VISITS

I (type in your name below)

the parent/guardian of

Give Louisiana Excel Care staff member (s) permission to visit with my child at school for services including but not limited to:

- Psychosocial skills training

- Service Integration (Observation and Redirection of off-task behaviors)

My child attends

What grade is your child in?

My child’s teacher’s / teachers’ name(s):

All recipients have the following rights:
The right to privacy, security, and respect of property.
The right to voice a complaint or concern regarding care or service.
The right to participate in all aspects of care/services and planning of care/services.
The right to refuse all or parts of his/her care to extent permitted by law.
The right to have resuscitative services withheld and life-sustaining treatment withdrawn.
The right to information about the cost of services that will be billed to his/her insurance(s) and/or self (verbally and in writing).
The right to information about the value or purpose of any technical procedure that will be performed, including the benefits, risks, and who will perform the task/procedure.
The right to information about ownership or control of the agency.
The right to review records.
The right to 24-hour crisis intervention.
The right to protection from abuse, neglect, retaliation, humiliation, and exploitation. However, Louisiana Excel Care, reserves the right to include emergency intervention and other special treatment interventions when necessary. When emergency intervention or other treatment interventions are used, Louisiana Excel Care assures that they will be administered with consideration given to the physical, developmental, and abuse history of the person served.

By signing below I acknowledge that the staff has explained my Rights and Responsibilities as a client of Louisiana Excel Care.

Recipient’s Name

I certify that I have explained the Rights and Responsibilities of Louisiana Excel Care client.

Authorized Representative:________ Date:

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Section A: Use or Disclosure of Health Information

By signing this Authorization, I authorize (bottom of form), the use or disclosure of my individually-identifiable health information maintained by: .

My health information may be disclosed under this Authorization to the following provider:

4348 Jeffrey Dr
Baton Rouge, LA 70816
Phone:(225) 361-0219

Health information includes information collected from me or created by or information received by the agency from another health care provider.

Section B: Scope and Use of Disclosure(check all that apply):

Health Information that may be used or disclosed through this authorization is as follows:

All health information about me, including my clinical records created or received by the Provider. This information may include, if applicable:

Information pertaining to the identity , diagnosis, prognosis or treatment for mental health, alcohol or drug abuse maintained by a federally-assisted alcohol or drug abuse program; or information concerning the testing for HIV (Human Immune Virus) and/or treatment for AIDS (Acquired Immune Deficiency Syndrome and any related conditions.

All health information about me as described in the preceding checkbox, excluding the following:

School Information Exchange:

My signature shall allow or school board to exchange information with Louisiana Excel Care Case Manager or Clinical Supervisor with regard to my child. I am open to having discussions regarding my child’s progress in school.

print name of school

Section C: Authorization Expiration

You may elect to put an expiration date in place for this authorization

or you may terminate this authorization at any time by submitting a written request at any time. Terminating this authorization will not have an effect on any action taken by Louisiana Excel Careh prior to receiving written notice. Should a written termination of authorization need to be submitted please submit it to the address listed in section A.

Section D: Important Miscellaneous Information

I understand that Louisiana Excel Care cannot guarantee that the recipient will not disclose the provided health information to a third party. The recipient may not be subject to federal laws governing privacy of health information.

I have read and understanding the terms and Authorization. I have had the opportunity to ask questions about the use or disclosure about my health information.

Print Name:

Relationship of Guardian to Client:

Recipient’s Name:

Parent/Legal Guardian:

Address:

Home Phone:

Alternate Phone:

PCP INFORMATION

Doctor’s Name or Clinic:

Address

Phone:

Fax:

Additional Contact:

Is there anyone else you would like to add as an emergency contact? Please give their name and phone number.

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Emergency Preparedness Questionnaire

Please provide us with your updated emergency contact information and contact information of your evacuation destination.

Employee/Client Name:

Emergency Contact:

Address:

Phone

Yes

If so, when?

Yes

Who will evacuate with you?

Yes

If not, whom can we contact to immediately reach you?

What is the best way to contact you? Phone, Text, Email, All Three

Any additional comments/information:

GRIEVANCE ACKNOWLEDGEMENT

When clients of Louisiana Excel Care have a grievance concerning the rehabilitation services that they are receiving, they may request in writing a meeting with the Clinical Manager.

By signing below, I acknowledge I am aware and understand Louisiana Excel Care Grievance Policy

Parent/Guardian (Initial):

Client Name:

Orientation Acknowledgment

I certify that I have explained all Louisiana Excel Care Policies and Procedures, Rights and Responsibilities to the client

Initial

Recipient’s Name:

Staff Signature ___________________ Date: _

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Client Abuse and/or Neglect

For more information see link on the top of the 1st page.

AUTHORIZATION FOR OUTPATIENT TREATMENT

(state your name below)

Date:

YYYY

I do hereby authorize Louisiana Excel Care it’s consultants, therapists, medical staff employees, and whomever else may be necessary to administer outpatient therapy and or procedures that are considered necessary for my treatment.

I understand that various procedures and treatments may be used and that liability of Louisiana Excel Care and its employees are limited only to negligence.

The services provided are as follows:

Assessment

Group Counseling

Education

Family Counseling

Psychiatric Evaluation

Other

Please list other providers (if other was checked above)

I furthermore, give Louisiana Excel Care staff to provide Emergency Medical Treatment if needed.

Staff Signature: __________________________

Date: _____________

Acknowledgement Receipt

Of

Notice of Right to Appeal Determinations

The Notice of Right to Appeal Determinations tells you how the agency uses and discloses information about you. Not all situations will be described. We are required to give you a notice of your right to appeal the determinations of service provision for the information we collect and keep about you.

have read or have been given a copy of the agency’s Notice of Right to Appeal Determination Process, and consent to the uses of my treatment/services.

Client's Inital

Staff Representative ____________________

Date: __________________

Second Party Involvement Authorization

I would like the individual(s) named below to be involved in my child’s treatment decisions and Community Psychiatric Support Treatment (CPST)/Psychosocial Rehabilitation (PSR).

I intend that this directive become effective immediately upon my signing.

I want this directive to remain valid until written submission of my intent to terminate it.

Printed Name:

Initial of recipient or legal Guardian:

Date

YYYY

Witness Signature ____________________

Client Abuse and/or Neglect

I read the Client Abuse and/or Neglet page from the link on the top of page 1.

Initial below:

Date:

YYYY

Staff Signature ______ Date:

CRISIS RESPONSE PLAN ACKNOWLEDGEMENT

I, (Enter your name below), do acknowledge that I am aware and understand Louisiana Excel Care’s 24 Hour Crisis Response Plan. CLIENT or PARENT/LEGAL GUARDIAN:

Date:

YYYY

STAFF SIGNATURE: _____________________________

Date: __________________

24-HOUR CRISIS RESPONSE HOSPITILIZATION PLAN

I have read the 24-Hour Crisis Response Hospitilization plan from the link on page 1.

Recipient' initial

Date:

YYYY

Staff Approved (CEO): _______________________________________________________

LA Excel Care

4348 Jeffrey Drive Ste. 102

Baton Rouge, La. 70816

Phone (225) 361-0219

I acknowledge that I have read and received a copy of LA Excel Care's 24 hours On Call Policy.

By signing below I acknowledge that I have read or received a copy of Louisiana Excel Care Recipient Handbook.

Initial of recipient or legal Guardian:

Print Name

Date

YYYY

Signature of Agency Representative_______________ Date _

Healthy Louisiana Mental Health Rehabilitation Member Choice Form

Member Information: I am requesting services from a mental health rehabilitation (MHR) provider. I understand that I have the right to choose an agency to provide services to me or my child. I understand that I may only receive MHR services from one provider unless my health plan makes an exception. I may change providers if I am not satisfied with the services.

If assistance is needed with finding an MHR provider, review the list of providers located at your health plan’s website below or call your plan for assistance.

1. Aetna: https://www.aetnabetterhealth.com/louisiana/find-provider
     or call 1-855-242-0802 Hearing impaired TTY/TDD 711
2. Amerihealth Caritas Louisiana
     http://www.amerihealthcaritasla.com/member/eng/tools/find-provider.aspx
    or call 1-888-756-0004; TTY 1-866-428-7588
3. Healthy Blue: https://www.myhealthybluela.com/la/care/find-a-doctor.html or call 1-844-227-8350
    (TTY 711)
4. Louisiana Healthcare Connections: https://providersearch.louisianahealthconnect.com/ or
    call 1-866-595-8133 (Hearing Loss: 711)
5. United Healthcare Community: http://www.uhccommunityplan.com/la/medicaid/healthy-louisiana.html
    or call 1-866-675-1607 TTY: 1-877-4285-4514

The provider that I have freely selected to deliver MHR services to me or my child is: Provider

Provider Name:

Provider Phone Number:

Provider Contact Name:

Provider Address:

By signing the form below, I understand that I have chosen to receive services from this MHR provider and I acknowledge that it is my responsibility to notify my previous provider so they can coordinate my care with my new provider. I understand that I am free to choose any MHR provider in my health plan’s network.

Member/Legal Guardian Signature (use your mouse)

Printed Legal Guardian Name (if applicable)

Date

YYYY

Providers Information: A Member Choice form is required prior to receiving any mental health rehabilitation services. . This form requires member/legal guardian signature, date, identified provider with telephone and contact name. The provider is responsible for coordinating the transition of care with the member’s previous provider prior to starting services.

____________________________________________________________________________________________________________________

Provider Signature

Date

Orientation Acknowledgment

By signing below I acknowledge that I have received a copy of Louisiana Excel Care Recipient Handbook.

Also, I have read the Orientation Acknowledgmen page seen on the link on the top of this page.

Recipient's Initials:

Date

YYYY

I certify that I have explained all Louisiana Excel Care Policies and Procedures, Rights and Responsibilities to the client:

Staff Signature:_________________ Date: _

AFTER HOURS & WEEKEND ON CALL COVERAGE POLICY

I have read the AFTER HOURS & WEEKEND ON CALL COVERAGE POLICY page seen on the link on the top on the 1st page.

Initilal Below:

Date:

YYYY

Sign your name below to agree to all of the initials above and read and agree to the links on the top of page 1.

Signature (use your mouse)

Date:

YYYY

Type in your name below

File / Image upload

Upload Document Copies: Identification Cards - Social Security Card - Medicaid Card

Delete all uploads

Choose files or drag here

Best Contact Time?

Patient Name Below

Medicaid Number: (to be filled out when you arrive at the facility) _____________________________

Soc. Sec. Number: (to be filled out when you arrive at the facility) _____________________________

CONTACT INFORMATION:

Mailing Address:(If different)

EDUCATION:

PRESENTING PROBLEM (S): Please check all that applies

PAST TREATMENT:

AUTHORIZATION FOR SCHOOL VISITS

Give Louisiana Excel Care staff member (s) permission to visit with my child at school for services including but not limited to:

- Psychosocial skills training

- Service Integration (Observation and Redirection of off-task behaviors)

By signing below I acknowledge that the staff has explained my Rights and Responsibilities as a client of Louisiana Excel Care.

I certify that I have explained the Rights and Responsibilities of Louisiana Excel Care client.

Authorized Representative:__________________________ Date: __________________

Section A: Use or Disclosure of Health Information

By signing this Authorization, I authorize (bottom of form), the use or disclosure of my individually-identifiable health information maintained by: .

My health information may be disclosed under this Authorization to the following provider:

4348 Jeffrey DrBaton Rouge, LA 70816 Phone:(225) 361-0219

Health information includes information collected from me or created by or information received by the agency from another health care provider.

Section B: Scope and Use of Disclosure(check all that apply):

Health Information that may be used or disclosed through this authorization is as follows:

Section C: Authorization Expiration

Section D: Important Miscellaneous Information

I understand that Louisiana Excel Care cannot guarantee that the recipient will not disclose the provided health information to a third party. The recipient may not be subject to federal laws governing privacy of health information.

I have read and understanding the terms and Authorization. I have had the opportunity to ask questions about the use or disclosure about my health information.

PCP INFORMATION

Additional Contact:

Emergency Preparedness Questionnaire

Please provide us with your updated emergency contact information and contact information of your evacuation destination.

GRIEVANCE ACKNOWLEDGEMENT

When clients of Louisiana Excel Care have a grievance concerning the rehabilitation services that they are receiving, they may request in writing a meeting with the Clinical Manager. By signing below, I acknowledge I am aware and understand Louisiana Excel Care Grievance Policy

Orientation Acknowledgment

I certify that I have explained all Louisiana Excel Care Policies and Procedures, Rights and Responsibilities to the client

Staff Signature ___________________________________ Date: _________________

Client Abuse and/or Neglect

For more information see link on the top of the 1st page.

AUTHORIZATION FOR OUTPATIENT TREATMENT

The services provided are as follows:

I furthermore, give Louisiana Excel Care staff to provide Emergency Medical Treatment if needed.

Staff Signature: __________________________

Date: _____________

Acknowledgement Receipt Of Notice of Right to Appeal Determinations

have read or have been given a copy of the agency’s Notice of Right to Appeal Determination Process, and consent to the uses of my treatment/services.

Client's Inital

Staff Representative ____________________

Date: __________________

Second Party Involvement Authorization

Witness Signature ____________________

Client Abuse and/or Neglect

I read the Client Abuse and/or Neglet page from the link on the top of page 1.

Staff Signature ______________________ Date:________________

CRISIS RESPONSE PLAN ACKNOWLEDGEMENT

STAFF SIGNATURE: _____________________________

Date: __________________

24-HOUR CRISIS RESPONSE HOSPITILIZATION PLAN

I have read the 24-Hour Crisis Response Hospitilization plan from the link on page 1.

Recipient' initial

Date:

Staff Approved (CEO): _______________________________________________________

LA Excel Care

4348 Jeffrey Drive Ste. 102

Baton Rouge, La. 70816

Phone (225) 361-0219

I acknowledge that I have read and received a copy of LA Excel Care's 24 hours On Call Policy.

By signing below I acknowledge that I have read or received a copy of Louisiana Excel Care Recipient Handbook.

Signature of Agency Representative_____________________________ Date _______________

Healthy Louisiana Mental Health Rehabilitation Member Choice Form

If assistance is needed with finding an MHR provider, review the list of providers located at your health plan’s website below or call your plan for assistance.

The provider that I have freely selected to deliver MHR services to me or my child is: Provider

____________________________________________________________________________________________________________________

Provider Signature

Date

Orientation Acknowledgment

By signing below I acknowledge that I have received a copy of Louisiana Excel Care Recipient Handbook.

Also, I have read the Orientation Acknowledgmen page seen on the link on the top of this page.

I certify that I have explained all Louisiana Excel Care Policies and Procedures, Rights and Responsibilities to the client:

Staff Signature:_______________________________________________ Date: _______________________________

AFTER HOURS & WEEKEND ON CALL COVERAGE POLICY

I have read the AFTER HOURS & WEEKEND ON CALL COVERAGE POLICY page seen on the link on the top on the 1st page.

Authorized Representative:________ Date:

4348 Jeffrey Dr
Baton Rouge, LA 70816
Phone:(225) 361-0219

When clients of Louisiana Excel Care have a grievance concerning the rehabilitation services that they are receiving, they may request in writing a meeting with the Clinical Manager.

By signing below, I acknowledge I am aware and understand Louisiana Excel Care Grievance Policy

Staff Signature ___________________ Date: _

Acknowledgement Receipt

Of

Notice of Right to Appeal Determinations

Staff Signature ______ Date:

Signature of Agency Representative_______________ Date _

Staff Signature:_________________ Date: _