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Client Intake Packet

Client Intake
Packet

A Path To Healing

Taking the first step can be the hardest. By filling out our client intake form, you're initiating your journey towards positive change. This crucial information helps us understand your needs and prepare to support you effectively.

Fill the form below to apply!

Financial Agreement

By filling your billing details, you acknowledge and understand that if you do not have insurance coverage. You may be billed by Guardian Therapeutic Center (GTC) for PRP services. 

You also understand that fees are collected monthly and that special circumstances can be discussed with the Program Director.

Insurance Information

Medical Assistance:

By filling out your Insurance Information, you request that payment of authorized Medical Assistance payments be made on your behalf to Guardian Therapeutic Center for any services furnished to you by that party who accepts assignment. Regulations pertaining to Medical Assistance assignment of benefits apply. 

You authorize any holder of Medical or other information about you to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medical Assistance claim. 

You understand that you request that payment be made and authorizes release of medical information necessary to pay the claim. If Item 9 of the HCFA-1500 Claim form is completed, you authorize releasing of the information to the insurance agency shown. In Medical Assistance assigned cases the physician or supplier agrees to accept the charge determination of the Medical Assistance that is charged, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medical Assistance. 

You authorize the release of information to Optum and the local Core Service Agency if you are a Medical Assistance Gray Zone client for the purposes of coordination of appropriate service. 

Emergency Information 

** If client is a child, will need a third emergency contact filled out on form. ** 

Transportation Authorization 

By filling this form and clicking the "Submit" button at the bottom of the form, you hereby authorize staff from Guardian Therapeutic Center to transport you as needed for the Psychiatric Rehabilitation Program and case management services.

Confidentiality & Privacy Practices Disclosure Statement 

With few exceptions, our conversations are confidential. State law, federal regulations and our code of ethics specifically guarantee this confidentiality. There are some situations, however, in which confidentiality cannot be guaranteed. They fall within the following categories: 

• We must notify the appropriate person if we feel you may harm  

another individual. 

• We must report any occurrence of abuse (past or present), neglect or 

exploitation of children or the elderly. 

• We are required to respond to a subpoena accompanied by a court order. 

• We will respond to any situation in which we believe you may harm yourself. 


Our Privacy Practices: Guardian Therapeutic Center, Inc. (GTC) promises to maintain the confidentiality of your protected health information (PHI). PHI is health information about you that we have in our records. We will not share this  

information, in whole or part, with any person or entity without your consent. In addition, we commit to delivering our services in a manner that maintains  

confidentiality. We will coordinate services with primary care physicians, referring agencies, schools or other stakeholders with your written consent. 


Federal & State Laws: We are required by federal regulations called the "HIPAA Privacy Regulations" to protect the confidentiality of your health information. We are also required to comply with state laws that are often more stringent than the federal regulations.  


Authorization to Disclose PHI: It is our practice to obtain your authorization or consent before we disclose your PHI to another person or entity. You may revoke your authorization or consent at any time and for any reason. 


How We Use Your Protected Health Information: We use your PHI solely for treatment, payment, and health care operations. For example, we may use your PHI to plan and provide your care and treatment; communicate with health care  

professionals; obtain payment for our services; educate and train our staff; and assess and improve our services. We are also permitted to use or disclose your health information if required by law. 


You’re Rights: You have a right to request a restriction on certain uses and disclosures of your PHI; inspect and copy your PHI; request amendments to your PHI; and obtain an accounting or list of disclosures your PHI. This access does not include records from outside agencies, such as hospitals, DORS, etc. Such as access to the file must be authorized by the Program Director, with a notation of date and time entered in the file. If it is felt that it would not be in the best interest of the  

member to access the file, a written summary of the file contents will be provided to the individual. A staff member must be present while the record is being reviews by the member to ensure that nothing is removed or changed with the file contents. A member who disagrees with the contents of his/her record will have the opportunity to submit corrections/ amendments, which would be included in the records. 


Our Duty: It is our duty to provide you with a copy of this disclosure statement for your personal records at the point of intake. A duplicate can be provided for you at any time upon request. 


For More Information or to Report a Problem: If you have questions or concerns regarding our privacy practices, feel free to contact, Program Director /Executive Director at (410) 394-9696. 


Acknowledgement: By filling this form and clicking the "Submit" button at the bottom of the form, you indicate that you have received a copy of the Confidentiality & Privacy Practices Disclosure Statement. 

Consent to Participate

By filling this form and clicking the "Submit" button at the bottom of the form, you agree to participate in the Psychiatric Rehabilitation Program (PRP) and will participate in the development of the Individual Rehabilitation Plan (IRP) for PRP services. You hereby give consent for services to be provided. I have been informed and received a copy of the Consumer Handbook and the Consumer Rights and Responsibilities.

NOTICE: This is an important legal document. 

Before submitting the form, you should know these important facts.


INTRODUCTION: 

Maryland law gives the right to anyone 16 years of age and over to be involved in decisions about their mental health treatment. However, a parent or guardian of a person under the age of 18 years may authorize treatment, even over the objection of the minor. The law also notes that at times, some persons are unable to make treatment decisions. Maryland law states that you have the right to make decisions in advance, including mental health treatment decisions, through a process called advance directive. An advance directive can be used to state your treatment choice or can be used to name a health care agent, which is someone that will make health care decisions for you. 


1. If you are a person with a mental health diagnosis, this document provides you the chance to take part in a major way in your mental health care decisions when you are not able to. This document allows you to express your consent or refusal of medications for your mental illness and other health care decisions, including use of seclusion and restraints. Please know that Maryland law allows health care providers to override your refusal for medication for a mental disorder in limited situations is you are involuntarily committed to a psychiatric hospital. 


2. This document may be completed by any individual 18 years of age and has not been determined to be not capable of making an informed decision. An advance directive may be oral or written. If written, it must be signed and dated. Two witnesses must also sign the document. The health care agent may not be a witness. At least one witness may not be a person who is knowingly entitled to benefit by your death, for example inherit money or insurance benefits. The witnesses must sign the document stating that the person making the directive is personally known to them and appears to be of sound mind. 


3. If you wish to guide your health care providers on what treatment you wish to have if you should become unable to give consent, and you DO NOT WANT A HEALTH AGENT, fill out the form titled "Advanced Directive for Mental Health Treatment". If you want an agent to make the choice for you, fill out the form "Appointment of Health    Care Agent". You may fill out both forms if you want an agent to make the choices and you also want to assist in those choices. If the directive is made orally, it must be made in the company of your attending physician and one witness. 


4. You can also make an advance directive naming a person as your health care agent, to make mental health decisions when you are not able to do so. The agent must make choices in line with any desires you have expressed in this document, or if your wishes are not expressed and are not known by the agent, the agent must act in good faith in what he/she believes to be in the best

interest for you. It is your job to inform the agent that the agent has been named in your advanced directive, and to make sure he/she agrees to be your agent. It is important that your health care agent be informed about your mental illness and the decisions you have made in this form. It is highly  

recommended that you discuss the contents of this form with your family and close friends and your mental health providers. 


5. Maryland Law does not allow a person to sign another adult into a psychiatric hospital. Therefore, a health care agent may not sign you into a psychiatric hospital. 


6. Maryland Law allows giving medication for the treatment of a mental disorder over the person's expressed wishes or placing a person in seclusion or restraints against the person's expressed wishes, under certain conditions.

Advanced Mental Health Directive

(Applicable if Age 16 or Older) 

Case Management/Entitlement Assessment

Below are government entitlements that Guardian Therapeutic Center can assist our clients with if he/she is eligible and indicates a need while in the program. Please indicate which entitlements you currently receive, need assistance with the application, or are not interested in receiving assistance with the application.

Entitlements Assistance Consent 

By your answers from the above form, you understand that it is the responsibility of Guardian Therapeutic Center to provide you with assistance in determining my eligibility and applying for Federal and State benefits (entitlements). You hereby authorize Guardian Therapeutic Center to research and apply for Federal/State benefits on your behalf, as a proxy or designated representative.


Furthermore, you understand that when services provided through Guardian Therapeutic Center have been terminated (for whatever reason), you are no longer eligible to receive entitlements assistance.


Should you decline to receive entitlements assistance at this time, you understand that you may request the service later.

Crisis Management Plan

Crisis is a sudden change in the client's behavior in response to stress or other painful feelings.  It is often negative due to the client's lack of experience or inability to cope with personal or inter-personal problems. 

The goals of crisis management are to: 

• provide immediate emotional support 

• reduce stress 

• decrease the risk of harm to self or others 

• teach better and more constructive ways for dealing with stress or other painful feelings 


Part of good crisis management planning is knowing what to expect. Generally, a person's response to stress or negative situations is the same. With that in mind, check the responses that relate to you. 

TIPS to Safely Manage a Crisis: 

1. Take a deep breath and recognize crisis by putting into prospective 

2. Try to control my behavior to harm self/others by taking a personal "time-out" 

3. Avoid drugs or alcohol 

4. Avoid use of all weapons 

5. Avoid threats/altercations with others by walking away from upsetting situations

6. Call your Social support


If my crisis has not been resolved after following the actions above, I agree to:

  1. First Call for Help Hotline Number: 410-685-0525 or 211(Baltimore) 

  2. Call a 24-hr crisis hotline: 

  • Baltimore City (410) 435-5717 

  • Baltimore County (410) 931-2214 

  • Columbia/Howard Co. (410) 531-6677 

  1. Go to nearest Hospital Emergency Room 

  2. Call 911 


When I call my Family Services Coordinator (during business hours) they may: 

1. Assess my crisis and attempt to assist me in resolution via phone 

2. May contact my SSP and/or emergency contact person to transport me to ER.

3. Call 911 on my behalf 

4. Discuss my crisis and medication with program director


By filling the above form and clicking the "Submit" button at the bottom of the form, you have accepted to adhere to our crisis management plan.

Authorization For The Release Of Health Information

This form allows you to authorize [PCP, MH/SA Provider, and Child’s School] to release your protected health information to Guardian Therapeutic Center. Please complete all sections of this form. This authorization is in accordance with federal privacy regulations (42 CFR § 164.508), HIPAA, and the Annotated Code of Maryland, Title 10 Health General Article §§ 4-301 – 4-307.

By filling this Authorization section of this form, you acknowledge that you understand the following:

  • This authorization is voluntary.

  • Your treatment, payment for it, and/or eligibility for enrollment or benefits cannot be conditioned on your signing this form.

  • You may receive a copy of this form.

  • You may inspect your protected health information without signing this form.

  • You may revoke this authorization at any time, except to the extent that action has been taken prior to receipt of your written revocation. To revoke, you must notify the Guardian Therapeutic Center’s Program Director in writing.

  • Once your information has been disclosed under this authorization, redisclosure by the recipient is possible, and the information may no longer be protected by federal regulations but may be protected by Maryland law.

Consent to Use and Disclose Your Health Information 

This form is an agreement between you, and Guardian Therapeutic Center. 


When we examine, diagnose, treat, or refer you, we will be collecting what the law calls Protected Health Information (PHI) about you. We need to use this information to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions. 


By filling this form and submitting it, you are agreeing to let us use your information here and send it to others.  The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information.

Please read the Notice of Privacy Practices before you submit this Consent Form. 


In the future we may change how we use and share your information and may change our Notice of Privacy Practice. If we do change it, you can get a copy by contacting our office at: (410) 394-9696 

If you are concerned about some of your information, you have the right to ask us not to use or share some of your information for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with your wishes. 


After you have submitted this form, you have the right to revoke it (by writing a letter tell us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on, but we have already used or shared some of your information and cannot change that.

Submitting This Form

By filling every section of this form and clicking the "Submit" button below, you acknowledge that you have read, understood, and agree to all the terms and conditions outlined in every section of this form; this is tantamount to a legally binding consent.

Guardian Therapeutic Center
Information & Referral Line

Call Today:

410-394-9696

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restores independence, and

promotes mental wellness.

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Crisis Hotline:

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Email:

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Phone:

410-394-9696

Phone:

443-552-3748

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