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The Crisis hotline provides 24/7 free and confidential support for people in distress,prevention and crisis

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New Patient Registration

New Patient Registrationtemplate2020-01-23T14:28:19+00:00

Step 1 of 16

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  • INTAKE SCREENING SUMMARY - GENERAL INFORMATION

  • EMPLOYMENT/EDUCATION

  • LEGAL STATUS

  • FINANCIAL INFORMATION

  • FAMILY MENTAL HEALTH HISTORY

  • Have client's family members been diagnosed with any of the following? Check all that apply

  • HEALTH AND MENTAL HEALTH INFORMATION

    Health History

  • Mental Health History

  • Abuse History

  • Substance Use

  • SIGNATURE

  • CONSENT FOR TREATMENT AGREEMENT

    I (we) hereby give my (our consent to The Potter’s House Family and Children Treatment Center to provide treatment for me (us) and/or for my minor child(ren) on an outpatient basis. The risks and benefits of treatment have been explained to me (us). I (we) also understand that clinical records may be reviewed by a Quality Assurance Committee and/or in clinical supervision to ensure quality treatment for my (our) family. Information necessary to carry out treatment, payment and healthcare operations will be submitted to appropriate organizations for accreditation, certification or authorizations. The Potter’s House Family and Children Treatment Center Client Grievance Procedures, Client Rights and Responsibilities and Notice of Privacy Practices have been explained to me and I have received my own copy. If our Privacy Practices should change, you will be notified of the change by receipt of the new Notice of Privacy Practices. The new Notice of Privacy Practices will also be posted. To provide treatment to minors, The Potter’s House Family and Children Treatment Center is required to obtain consent for treatment from the minor’s legal guardian or custodian. By signing below, you are attesting that you are legally responsible for the minor named below.

  • RIGHT TO REFUSE TREATMENT

    You have the right to refuse treatment. If you refuse treatment, The Potter’s House Family and Children Treatment Center staff will, with your approval, offer assistance in developing alternative approaches to ensure you and/or your minor child (ren) receive the needed or recommended services. If you refuse treatment, please see The Potter's House administrative staff.

  • RIGHT TO WITHDRAW CONSENT FOR TREATMENT

    You have the right to withdraw consent for treatment at any time. If you choose to withdraw consent, The Potter’s House Family and Children Treatment Center staff will explain any implications or potential consequences for refusing treatment. If you have chosen to withdraw consent for treatment, please see The Potter's House administrative staff.

  • SIGNATURE

  • RECEIPT AND ACKNOWLEDGEMENT OF HIPAA NOTICE OF PRIVACY PRACTICES

    I hereby acknowledge that I have received and have been given an opportunity to read a copy of the HIPAA Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my Privacy Rights, I can contact The Potter’s House Family and Children Treatment Center at (678) 330-1400 or the Regional Office for the Department of Health and Human Services (DHR).

  • SIGNATURE

  • RECEIPT AND ACKNOWLEDGEMENT OF POLICIES AND RIGHTS

  • SIGNATURE

  • TRANSPORTATION AUTHORIZATION

    Emergency Contact Information

  • In case of an emergency and the parent(s)/guardian(s) cannot be reached, please contact one of the following persons:

  • Authorization for Emergency Medical Care

    In case of an accident or illness requiring medical attention, the undersigned authorize The Potter’s House Family and Children Treatment Center to call a health provider or take my child to the nearest hospital or doctor, and it is understood that if possible, their services will be obtained. If neither parents nor preferred care provider can be contacted, The Potter’s House Family and Children Treatment Center is authorized to contact another health care provider. It is also understood that this agreement covers only those situations, which in the best judgment of The Potter’s House Family and Children Treatment Center are true emergencies.

  • ACKNOWLEDGMENT OF SERVICE REQUIREMENTS

  • ACKNOWLEDGMENT OF SERVICE REQUIREMENTS

    It is the policy of Department of Behavioral Health and Developmental Disabilities that an individual must have a verified diagnosis within the first 30 days of intake in order to continue to meet the diagnostic criteria and continue services.

  • SIGNATURE

  • ACKNOWLEDGMENT OF NO-SHOW POLICY

    A no-show is defined as failure to keep your appointments without prior notification. If you cannot attend your appointment you are expected to contact your therapist or the Administration staff 24 hours prior to your appointment. Calling a few minutes prior to your session will be deemed as a no-show. The Potters House Family and Children Treatment Center will charge a No-show/Cancelation fee in the amount of $ 25. To prevent from being charge this fee, all appointments must be confirmed 24 hours in advanced. Please know that we do understand that emergencies will occur; however, we expect you to call 24 hours prior to your scheduled appointment to avoid a no-show infraction and a no-show fee. Also, please understand the importance of complying with all appointments as they have a vital effect on your family quality and continuity of service

  • The Potter’s House Family and Children Treatment Center will take the following actions for no-shows:

    1. After the first no-show the provider will talk with you about your attendance and compliance with services and fee assessed.
    2. After the second no-show the provider will send you a non-compliance letter and you will be asked to address the non-compliance with the Clinical Director at The Potter’s House Family and Children Treatment Center.
    3. After the third no-show you will be discharged from The Potter’s House Family and Children Treatment Center and will be provided with a minimum of 1 referral to a different agency that provides counseling.
  • SIGNATURE

  • HANDBOOK FOR PERSONS RECEIVING SERVICES

    CONTENTS

    I.Mission and Philosophy of The Potters House

    II.Hours of Operations

    III.Program Description

    IV.Team Composition

    V.Admissions Criteria

    VI.Behavioral Assessment/Individual Resiliency Plan

    VII.Discharge Plan

    VIII.Transfer and Re-Entry

    IX.Financial Obligations

    X. Client Satisfaction

    XI. Consumer Rights

    XII.Consumer Responsibilities

    XIII.Code of Ethics

    XIV.Non-Discrimination Policy

    XV.Confidentiality Policy

    XVI.Safety Procedures

    XVII.Smoking Policy

    XVIII.Drug Use Policy

    XIX.Grievance and Appeal Procedures

    XX.Medication Policy

    XXI.Weapons

    XXII.Notice of Privacy Policy

    XXIII.No-Show Policy

  • SIGNATURE

    By signing below, I attests that I am legally responsible for the minor named (if applicable) and that I have read and fully understand and acknowledge receipt of Labwork Policy, Prescription Policy, Consumer Bill of Rights, Consumer Grievance, Service Requirements, No-Show Policy and Diagnostic Assessment Contract, policies as a participant in The Potter’s House Family & Children Treatment Center.I understand that if at any time I have questions about any of the sections, I may request to speak to a representative of The Potters House.

Our Mission

NBT believes that through empowerment and education, children, adolescents, and adults can address challenging situations that interfere with their normal level of functioning. We believe that providing a comprehensive range of services can assist in meeting the unique needs of each individual and/or family.

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Atlanta, GA Office

5680 Fulton Industrial Blvd.
Atlanta, GA 30336
Office (404) 346-3471
Fax (404) 346-3473
info@nbthealth.com

Albany, GA Office

1120 Westbroad Ave. Ste. B2
Albany, GA 31707
Office (229) 903-1151
Fax (229) 901-1149

Other Office’s

Covington, GA Office

5108 Newton Dr.
Covington, GA 30014
Office (404) 346-3471
Fax (404) 346-3473

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