PROJECT COURAGE Plain English Consumer Advisory file · Web view251 Main Street Unit 101Old...

Welcome toPROJECT COURAGE

Though lengthy, it is very important that you read this document. It will cover much of the information you will need to orient you to PROJECT COURAGE and our policies, including important topics such as confidentiality, how we handle crises, logistics such as session length, and much more. Please take the time to read this through before signing off that you have done so. Thank you.

251 Main Street Unit 101Old Saybrook, CT 06475

www.projectcourageworks.com

Dear Client,

We realize that it’s likely been a “hard road” to get here and so, on behalf of all the staff here, we’d like to say welcome – we’re glad you’re here. Our ultimate goal is to help you in your personal growth process.

As we move forward together, please feel free to ask me any questions regarding your treatment or progress, and let me know if there is a better way I can assist you.

Sincerely,

Andy Buccaro, LCSW, LADCExecutive DirectorProject Courage860-388-9656251 Main StreetOld Saybrook, CTprojectcourageworks.com

This form provides clients with information about policies and procedures. This form is NOT legal or clinical advice.



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Part I:About PROJECT COURAGE

PROJECT COURAGE is committed to providing professional mental health and substance abuse care to all of our clients. As part of the delivery of our services we feel it is important to inform you, the consumer, as to what you can expect from PROJECT COURAGE and any risks or limitations that may be involved with our service provision.

Our Mission Statement:Project Courage provides specialized addiction treatment for adolescents and young adults that is client centered and addresses obstacles that have plagued the addiction treatment industry; We believe addiction is an opportunity for change.

Our StaffAndy Buccaro, LCSW, LADC. Andy is the Executive Director and founder of Project Courage. Before launching Project Courage, he was the Director of School-Based Programming for New Hope Manor Inc. In this role, Andy worked with public and private schools arranging contracts to allow schools to supplement their support staff with substance abuse counseling. Additionally, Andy worked as a clinician for Yale University’s Forensic Psychology Department in their research project comparing Cognitive Behavioral Therapy with Twelve Step Facilitation models for treating alcoholism and addiction. During this time, he also provided clinical services for Yale’s adolescent substance abuse prevention program for students re-entering New Haven Public Schools. Most recently he served as the Executive Director of Center for Change an intensive outpatient dual diagnosis clinic that delivered services to Turning Point a nationally recognized treatment program for young adult males. At Center for Change he developed, implemented, and produced clinical programming that received accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF). With credentials in both the mental health and substance abuse fields, combined with almost two decades of experience, Andy provides clinical services that include thoughtful, compassionate and confidential interventions. Andy’s specialties include substance abuse and anxiety disorders.

Ryan Hocking LCSW. Ryan earned his BA in Sociology from the University of New Hampshire and his Masters in Social Work from Southern Connecticut State University. Ryan started his career working at the Rushford Center, Inc. where he provided services to adolescents with mental health and addiction issues. His work there included biopsychosocial assessments, individual, family and group therapy. From Rushford, Ryan continued his social work career as a




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supervisor at the APT Foundation where he offered individual and group therapy to patients receiving opioid replacement treatment. Ryan most recently worked as the Assistant Executive Director at Center for Change, an intensive outpatient dual diagnosis clinic that delivered services to Turning Point a nationally recognized treatment program for young adult males. Ryan brings his dedicated work in the social work field to Project Courage and feels passionate about helping individuals and families achieve their treatment goals.

Greer Richardson, MD. PSYCHIATRIST Dr. Richardson graduated from Yale University, Department of Psychiatry in 2001 and began treating veterans with posttraumatic stress disorder and co-occurring illnesses such as substance use disorders, anxiety disorders, mood disorders and psychotic disorders. He has been in private practice since 2003 and treats a variety of illnesses, the majority of which have co-occurring substance use disorders. He is a national trainer for Cognitive Processing Therapy, a cognitive behavioral therapy for PTSD. He is a diplomat of the American Board of Psychiatry and Neurology and an Assistant Clinical Professor of Psychiatry at Yale University where he teaches Yale residents general psychiatry. He graduated from Baylor University with a BA in Philosophy and a minor in Physics and earned his MD from the University of Tennessee.

TIM HARMON – HEAD OF ADMISSIONSTim is currently attending Southern Connecticut State University where he plans to achieve his BA in social work and then work on earning his Masters. Tim takes on multiple roles at Project Courage. As the Care Coordinator, Tim is involved with much of the work behind the scenes with administering drug testing, as well as assisting around the office. As a Recovery Coach, Tim works with people to help remove obstacles in their life that could potentially be getting in the way of keeping them sober

Courtney Bushnell, LCSW- CLINICAL SUPERVISOR Courtney is a Licensed Clinical Social Worker. She received her Bachelor’s degree in social work from Providence College and then went on to receive a Master’s degree in social work from the University of Connecticut. Before joining Project Courage, Courtney was an Outpatient Coordinator at UCFS in Norwich, providing a range of clinical care including biopsychosocial assessments, individual, group and family therapy to people of all ages, focusing on substance use and mental health issues. Courtney is very passionate about creating a positive working therapeutic relationship and helping individuals and families work toward achieving their goals. “Nothing changes if nothing changes”

Kerry Law MFT, LADC. FAMILY THERAPIST Kerry Law is a licensed drug and alcohol counselor and has a masters degree in marriage and family therapy. Kerry's practice focuses on working with individuals and families impacted by substance abuse and other mental health disorders. Kerry's experience includes 20 years in public service along with her work in an outpatient, residential and medicated assisted treatment programs




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MICHELLE BAILEY – OPERATIONS MANAGERMichelle has a dual role at Project Courage, Office Manager and Fitness Coordinator. Michelle has her Bachelor of Science degree in Business Management with a concentration in health care and a Master’s degree In Business Administration from Quinnipiac University.Michelle is a certified personal trainer, group fitness instructor and yoga instructor with a passion for life that is unstoppable. Michelle believes how you work out, is how you live your life and motivates people to reach their fullest potential.

JOSEPH M. CRISCUOLO, CAC, CRPS, RSS – PRIMARY CLINICIAN & RECOVERY COACHJoe provides support to both clients and family members in his role at Project Courage. Before joining Project Courage, Joe provided Recovery Coach Support Services while employed at Aware Recovery Care. Joe has been involved in recovery for 22 years and is a member of the VIP Mentoring Program, performing volunteer service in the Bridgeport and Cheshire criminal justice system. Joe has facilitated 12 step meetings at Bridgeport Mental Health and the Prospect House. He is a Certified Addiction Counselor, (CAC), and is currently pursuing his Drug & Alcohol Recovery Counselor (DARC) at Gateway Community College. Joe also holds certifications as a Certified Recovery Peer Support (CRPS) and Recovery Coach Specialist (RSS).

TINA CAMPBELL – BILLING MANAGERTina brings her extensive experience in business administration and business management to Project Courages’ Billing Department. Tina has owned and managed her own business for over 10 years, has coached gymnastics for over 30 years, and believes that her compassion for others will be her greatest asset and help with her goal of making someone smile every day.

BEN BACKES – SCHOOL BASED COUNSELORBen is a school-based, substance use counselor at Project Courage, providing middle and high school students with individual substance use counseling within their learning environment. Ben brings experience with Medicated Assisted Treatment (MAT), individual, group, and family counseling. He has worked with a variety of individuals suffering from substance abuse and other mental health disorders. Ben received his Associates Degree and DARC Certificate from Gateway Community College in Drug and Alcohol Recovery Counseling, his Bachelors Degree in Social Work from Southern Connecticut State University, and is currently attending Fordham University where he will receive his Master’s Degree in Social Work this spring

JEAN WATSON – PRIMARY CLINICIANJean earned her BA from Albertus Magnus College with a major in Psychology and a minor in Sociology. She earned her Master’s in Social Work from Southern Connecticut State University with a primary focus on Medical Social Work. Jean’s primary experience has been with the criminal justice system, specializing in sexual behaviors and compulsivity resulting in her CATSO (Connecticut Association for the Treatment of Sexual Offenders) certification. Additionally, Jean’s experience has focused on substance use and mental health disorders. Jean’s work includes individual treatment, family work, and group sessions. Jean is also a Register Yoga Teacher; her treatment work values and implements mindfulness and spirituality.




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ROB DEFFENDALL – DIRECTOR OF RECOVERY SUPPORT SERVICESRob brings his 9 years of work in the recovery field and extensive involvement in the recovery community to Project Courage. Rob spent two years at Grant Street Partnership as a Residential Aide, five years at Turnbridge as a Case Manager and Support Staff Director while earning the title of 2014 Case Manager of the year, and previous to that, two years as Director of Residential Services at Westport House. Rob has over 10 years in sobriety, and is currently working on his CADC certification.

CHELSEA VERNI – RECOVERY COACHChelsea’s work is designed to support clients with their journey to recovery through goal setting, finding purpose, building community, and working on the client’s overall health. Chelsea utilizes her background as a certified yoga instructor by incorporating the philosophies she uses in her daily practice into her work here at Project Courage. She is currently working towards her BS in Psychology at Southern CT State University.

ANDREW LOCKE – RECOVERY COACHDrew initially went to college for business and finance. After two semesters he decided that staring at numbers all day was not for him. He switched to his other passion in life – psychology and helping others with their mental health. He graduated from the University of Connecticut with a BA in Human Development and Family Studies and began a career in different coaching and leadership positions. Most influential to Drew’s professional development was his time at Brian Gibbons Homeless Outreach in Waterbury, Connecticut which served as a raw introduction to substance use and specifically the opioid crisis. From there he moved on to a medical social work internship at Saint Raphael’s Hospital of the Yale New Haven Health network and once again was struck by the quantity of substance use cases he encountered. Drew is passionate about investigating the family dynamic in client’s lives as it plays a pivotal role in recovery. He takes pride in his assertive and honest leadership style, and knows that it takes observing the truth to effectively progress in life which he delivers to our clients and families

What Services does PROJECT COURAGE offer? Our goal is provide confidential, compassionate, and comprehensive services in one setting including but not limited to:

Individual counseling Family counseling Group counseling Assessment Referral Support groups Advocacy Consultation Professional training




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How does PROJECT COURAGE deliver its services? What follows is a description of how a typical progression in treatment might look. Extenuating circumstances may change this portrayal drastically, i.e. if an individual was in crisis, the clinical progression would look much different.

Outpatient Treatment (typically 1-3 hours per week):In the initial session at PROJECT COURAGE we will focus on completing an assessment. This can take anywhere from one to two hours. In addition to the initial assessment we will also have our clients meet with our consulting physician, so that he/she can also provide an additional screen for substance abuse and mental health. Upon completion of the assessment the professional at PROJECT COURAGE will compile an assessment summary and the client will be assigned a Primary Clinician. The Primary Clinician will arrange a time to meet with the client to review the assessment summary and other appropriate individuals (provided consent is given to do so). From here, additional appointments will be made and an action plan is developed in collaboration with the client, to address those issues that have brought the client to treatment. The action plan includes goals, objectives, and estimated timelines to achieve such goals. Additionally, the action plan may include frequency of appointments and the configuration of appointments (i.e. individual sessions, family sessions, group sessions, toxicology screens, or a combination of these). Outpatient sessions are typically forty-five minutes in length unless otherwise specified (family sessions at times will last 80 minutes, and some groups are longer as well). Finally, for clients who are receiving services at PROJECT COURAGE for reasons related to the use of substances, we require regular and random urine screens. Urine screening at PROJECT COURAGE is not meant to be, nor is used as a punitive measure, but rather as a means to provide a method of monitoring effectiveness of treatment and as a motivational tool for clients attempting to remain abstinent.

Intensive Outpatient Programming (typically 15-17 hours per week):In many ways the initial intake process is similar for our intensive outpatient (IOP) clients. Once the assessment is completed our IOP clients are enrolled in our programming. They will attend groups for 9-15 hours per week, a one hour individual therapy session once per week, and if necessary receive medication management services. As with our outpatient services an action plan will be developed with the client, we will require our clients to meet with our consulting physician, and finally we will require random urine screens. Our IOP program typically lasts for 6-8 weeks, at which point many of our clients will enact a discharge plan that involves “stepping down” to outpatient level of care and remaining under the care of PROJECT COURAGE.

Recovery Support Services (community based treatment up to one year): Historically, treatment for substance Use Disorders (SUD) has been acute in nature resulting in short treatment duration with arbitrary timelines based on mandates by insurance reimbursement. More recently there has been a paradigm shift, and the behavioral health industry is coming around to acknowledging that SUDs are chronic in nature and like many chronic disorders (diabetes, hypertension, etc.) often require dramatic lifestyle changes. There are four domains




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that SAMHSA identifies as critical to develop for lasting recovery Health, Home, Purpose, and Community. To help our clients promote development in these 4 areas, Recovery Support Services at Project Courage offers up to a year of intensive case management. Clients in the Recovery Support Services program are assigned a Courage Wellness Team consisting of Recovery Coach, Registered Nurse, Therapist, and Psychiatrist. Our recovery coach and nurse will come to your home, to your community, to your coffee shop. We’ll use a variety of strategies to foster opportunities for recovery including urine screening, mobile application technology, transportation (limited to first month) and access to gym membership. Below is a breakdown of the minimum amount of hours spent in the community with the Recovery Coach and Registered Nurse.

Weeks 1 2-4 5-8 9-26 27-52

R.C. 8-11 hrs Min of 4 hrs Min of 4 hrs Min of 2 hrs Min of 1 hrs

Nurse 2 hrs 1 hr 1x month 1 month 1x every 3 months

What theory base does PROJECT COURAGE employ? Developmental TheoryPROJECT COURAGE makes use of a developmental theory base. This means that we believe individuals develop emotionally, socially, physically, cognitively, morally, and spiritually over the course of their lives. Optimal development occurs when an individual’s genetic and biological make-up is well matched with his/her environment (i.e. family of origin, school, peer group, etc.). Certain variables in life—such as stress—can derail development and cause distress to the individual and those around him/her. For example, a boy who was repeatedly bullied throughout his elementary school years may not have developed socially and so as an adult struggles making connections with his co-workers. This understanding is paramount and guides PROJECT COURAGE in its considerations of causation, diagnosis, and treatment. In this sense we believe we’re offering “habilitation,” not rehabilitation by using evidence based treatment models forged for young people. Because we make use of a developmental model we believe in working the “whole” person rather than just pathologizing our clients.

Brain-In-Environment (BIE)With the onset of ever more sophisticated brain imaging technologies, the mental health field is viewing mental health and substance abuse disorders as physiologically based rather than psychologically based. PROJECT COURAGE engages with each client in regular practices to help optimize the functioning of their identified brain structures and specific brain pathways. Alcohol and drug abuse and dependence is viewed as a disease of the brain with behavioral consequences. Additionally, when possible all treatment is guided and informed by brain based research and findings.

Change TheoryChange theory assumes that all change in human behavior progresses through clear stages, and that it is significant to identify which stage of change an individual is in so that appropriate interventions can be selected. Different levels of change can be easily identified when working with individuals who are struggling with issues of substance abuse and/or mental health. For




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example, some clients feel their substance abuse, behavior, thinking, or emotion is not problematic, others feel it is problematic yet have no desire to change, and still others are ready to address their issue and begin the change process. Employing this model allows us to meet our clients at their level of change and avoid many of the pitfalls set up by other models that expect clients to fit into their concept of change.

Cognitive Behavioral TheoryCognitive behavioral theory (CBT), including rational emotive theory, has proven to be successful in the treatment of many mental health conditions. The assumption of CBT is that by identifying self-defeating behaviors and thoughts, one can then begin the process of replacing them with more productive thinking and acting. When used appropriately interventions from this theory base can empower clients by allowing them to take responsibility for their difficulties and effecting change in their own lives. A particular form of CBT that we employ at PROJECT COURAGE is Acceptance and Commitment Theory. This form of CBT shifts the focus away

from controlling or avoiding problems and moves clients toward accepting that struggles are part of life. From here the client is aided in committing to living a valued life despite experiencing “life on life’s terms.” This paradigm shift dovetails nicely with the work our clients are engaged in not only with their mental health and substance abuse but also the Twelve Steps.

Systems TheoryPROJECT COURAGE also makes use of a systems theory base. Most of us interact with a family, work or school, a set of friends, etc. These constitute systems; thus, we have a family system, a school system, an occupational system, and so on. A systems model focuses more on the interactions between individuals and their correspondent systems. When we work with clients we’re often interested in how they interact with the systems in their lives, and what can be done to facilitate change via such interactions. So, if you are a parent of the individual receiving services do not be surprised if we would like to work with you in addition to your son or daughter.




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Part II: Risks Involved in Treatment

Risks to your Privacy & ConfidentialityIf you have not already reviewed the document entitled Notice of Privacy Practices please know that this will further elaborate on issues salient to confidentiality. If you have already read this material please do NOT bypass over the following important material.

Social Workers’ responsibility is to promote the well-being of clients. In general, clients’ interests are primary. However, social workers’ responsibility to the larger society or specific legal obligations may on limited occasions supersede the

loyalty owed clients, and clients should be so advised.

-The National Association of Social Work’s (NASW) Ethical Standards for Social Workers.

The confidentiality of your information is an important issue to discuss with regard to risks to you. As professionals in the substance abuse and mental health fields we are required by both state and federal laws to keep your personal information confidential. HOWEVER, there are clear limits to confidentiality that you MUST be informed of. We will describe these exceptions here:

Duty to warn and protectWhen a client discloses intentions or a plan to harm another person, 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.

Abuse of children and vulnerable adultsIf 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. Keep in mind that we need only have sufficient reason to suspect such abuse in order for a report to be necessary. Also, know that many times things occur that some individuals might not consider abusive or negligent. For example, prenatal exposure to controlled substances, driving an automobile while under the influence of a substance with a minor in the car, and repeatedly neglecting to take your child to appropriate medical care, would all be considered reportable offenses.

In the event of a client’s deathIn the event of a client’s death, the spouse or parents of a deceased client may have a right to access their child’s or spouse’s records.

Professional misconductProfessional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held




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regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.

Court ordersHealth care professionals are required to release records of clients when a court order has been placed.

If you are a Minor (under age 18)In some case parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.

When insurance companies are paying the cost for servicesInsurance companies and other third-party payers are given information that they request regarding services to clients. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.

When booking appointments, arranging for payment or other administrative duties.PROJECT COURAGE uses an office manager to perform many administrative duties including scheduling appointments, preparing monthly statements, data entry, etc. This individual understands that client records including, demographic, biographic, insurance, financial, and clinical information are confidential and are subject to requirements of PROJECT COURAGE’s privacy policies. This individual will only access that information which is needed to perform their work and/or related duties. Failure to maintain client confidentiality is considered reason for immediate termination.

Supervision and/or consultation with or from colleaguesInformation about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed.

When attempting to secure paymentPayment is expected at the time of service. When fees for services are not paid in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, case notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client’s credit report may state the amount owed, time frame, and the name of the clinic.

We will take real and specific measures to protect your confidentiality including the following:

Though it may not be necessary (see the above limitations of confidentiality), and when appropriate, we will seek to receive authorization from you prior to any disclosure.

Protecting written and electronic records by keeping them in a secure location. Maintaining your records after service provision has terminated in a secure location in

accordance with the time schedule set by the National Association of Social Workers.




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Discussing with you and other interested parties (i.e. parents, family) the limitations to your rights of confidentiality.

Limiting any disclosure we must make to that which is needed to achieve the desired purpose.

Informing you of, to the extent possible, any associated consequences of such disclosures.

Risks not involved with confidentiality. The provision of mental health services involves risks beyond those associated with the limits to confidentiality. An exhaustive list of such risks is beyond the scope of this document, yet some notation of a fairly typical one is warranted here. By the nature of our work most of the individuals we work with will at times experience some level of emotional distress. Often times when people try new behaviors, or change old patterns it can be painful lending credence to old saying “It gets worse before it gets better.” In other words, there are times when you may think, feel, or talk about uncomfortable things both during our session and after them.

Staff Initial ________ Client Initial _________




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Part III: NOTICE OF PRIVACY PRACTICES

The privacy of your health information is important to us. We will maintain the privacy of your health information and we will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

A new federal law commonly known as HIPAA requires that we take additional steps to keep you informed about how we may use information that is gathered in order to provide health care services to you. As part of this process, we are required to provide you with the attached Notice of Privacy Practices and to request that you sign the attached written acknowledgement that you received a copy of the Notice. The Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information we maintain about you and a brief description of how you may exercise these rights.

If you have any questions about this Notice please contact: Andy Buccaro, LCSW, LADCPROJECT COURAGE LLC, 251 Main Street, Suite 101Old Saybrook, CT 06475, Phone: (203) 623-2291 (860) 388-9656




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PROJECT COURAGE, LLC251 Main Street, Suite 101Old Saybrook, CT 06475

Phone: (203) 623-2291 (860) 388-9656

NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by applicable federal and state law to maintain the privacy of your health information, we are also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information (“Protected Health Information” or “PHI”). We must follow the privacy practices that are described in this Notice (which may be amended from time to time).

For more information about my privacy practices, or for additional copies of this Notice, please contact us using the information listed in Section II G of this notice.

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATIONA. Permissible Uses and Disclosures without Your Written AuthorizationWe may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

1. Treatment: We may use and disclose PHI in order to provide treatment to you. For example, we may use PHI to diagnose and provide counseling service to you. In addition, we may disclose PHI to other health care providers involved in your treatment.

2. Payment: We may use or disclose PHI so that services you receive are appropriately billed to and payment is collected from, your health plan. By way of example, we may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.

3. Health Care Operations: We may use and disclose PHI in connection with our health care operations, including quality improvement activities, appointment reminders, training programs, accreditation, certification, licensing or credentialing activities.

4. Required or Permitted by Law: We may use or disclose PHI when we are required or permitted to do so by law. For example, we may disclose PHI to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities: health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners medical examiners, and correctional institutions or otherwise as authorized by law

B. Uses and Disclosures Requiring Your Written Authorization




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1. Psychotherapy Notes: Notes recorded by your clinician documenting the contents of a counseling session with you (Psychotherapy Notes) will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.2. Marketing Communications: We will not use your health information for marketing communications without your written authorization.3. Other Uses and Disclosures: Uses and disclosures other than those described in Section l.A. above will only be made with your written authorization. For example, you will need to sign an authorization form before we can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.

II. YOUR INDIVIDUAL RIGHTS

A. Right to Inspect and Copy. You may request access to your medical record and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny access to your records. We may charge a fee for the costs of copying and sending you any records requested. [State law may regulate such charges.] If you are a parent or legal guardian of a minor, please note that certain portions of the minor’s medical record will not be accessible to you.

B. Right to Alternative Communications. You may request, and we will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.

C. Right to Request Restrictions. You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. We are not required to agree to any such restriction you may request.

D. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by us after April 14, 2003. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.

E. Right to Request Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

F. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.

G. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that we have violated your privacy rights, you may contact Andrew Buccaro at Suite 101, 251 Main Street Old Saybrook, CT 06475, (203) 623-2291. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint with the Director.

III. EFFECTIVE DATE AND CHANGES TO THIS NOTICEA. Effective Date: This Notice is effective on April 14, 2003.

B. Changes to this Notice: We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in the waiting area of our office. You may also obtain any revised notice by contacting the director or office manager.




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Part IV: Your Rights & Responsibilities & PROJECT COURAGE Program

RulesStatement of Client Rights

All individuals requesting services from Project Courage have a right to receive such services without regard to race, ethnicity, age, color, religion, creed, gender, national origin, sexual orientation, veteran status, financial condition, handicap or disability, HIV infection. No distinction will be formulated in determining eligibility for participation in services provided by PROJECT COURAGE based on any of these identifiers, conditions or circumstances.

All individuals requesting services from PROJECT COURAGE shall receive a Statement of Client Rights as part of the intake and initial orientation process. Said statement shall include, but not be limited to the following client rights:

(1) The right to be treated with consideration and respect for personal dignity, autonomy, and privacy, without abuse, neglect or humiliation;

(2) The right to not be exploited. (3) The right to service in a humane setting which is the least restrictive feasible as defined in

the treatment plan; (4) The right to be informed of one’s own condition, of proposed or current services, treatment

or therapies, and of the alternatives; (5) The right to consent to or refuse any service, treatment, or therapy upon full explanation of

the expected consequences of such consent or refusal. A parent or legal guardian may consent to or refuse any service, treatment or therapy on behalf of a minor client;

(6) The right to a current, written, individualized service plan that addresses one’s own mental health, physical health, social and economic needs, and that specifies the provision of appropriate and adequate services, as available, either directly or by referral;

(7) The right to active and informed participation in the establishment, periodic review, and reassessment of the service plan;

(8) The right to freedom from unnecessary or excessive medication; (9) The right to freedom from unnecessary restraint or seclusion; (10) The right to participate in any appropriate and available agency service, regardless of

refusal of one or more other services, treatments, or therapies, or regardless of relapse from earlier treatment in that or another service, unless there is a valid and specific necessity which precludes and/or requires the client’s participation in other services. This necessity shall be explained to the client and written in the client’s current service plan;

(11) The right to be informed of and refuse any unusual or hazardous treatment procedures; (12) The right to be advised of and refuse observation by techniques such as one-way vision

mirrors, tape recorders, televisions, movies, or photographs;




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(13) The right to have the opportunity to consult with independent treatment specialists or legal counsel, at one’s own expense;

(14) The right to confidentiality of communications and of all personally identifying information within the limitations and requirements for disclosure of various funding and/or certifying sources, state or federal statutes, unless release of information is specifically authorized by the client or parent or legal guardian of a minor client or court-appointed guardian of the person of an adult client;

(15) The right to have access to one’s own psychiatric, medical or other treatment records, unless access to particular identified items of information is specifically restricted for that individual client for clear treatment reasons in the client’s treatment plan. “Clear treatment reasons” shall be understood to mean only severe emotional damage to the client such that dangerous or self-injurious behavior is an imminent risk. The person restricting the information shall explain to the client and other persons authorized by the client the factual information about the individual client that necessitates the restriction. The restriction must be renewed at least annually to retain validity. Any person authorized by the client has unrestricted access to all information. Clients shall be informed in writing of agency policies and procedures for viewing or obtaining copies of personal records;

(16) The right to be informed in advance of the reason(s) for discontinuance of service provision, and to be involved in planning for the consequences of that event;

(17) The right to receive an explanation of the reasons for denial of service; (18) The right not to be discriminated against in the provision of service on the basis of religion,

race, color, creed, sex, national origin, age, lifestyle, physical or mental handicap, developmental disability, or inability to pay;

(19) The right to know the cost of services; (20) The right to be fully informed of all rights; (21) The right to exercise any and all rights without reprisal in any form including continued

and uncompromised access to service; (22) The right to file a grievance; and (23) The right to have oral and written instructions for filing a grievance.

Grievance - Perceived Violation of Client Rights: The Executive Director or his designee shall serve as Client Rights Representatives for Project Courage and shall function in this capacity as specified in the Client Grievance Policy.

By signing below, I signify that I have read and understood, and have had ample time to read and consider my rights as a client of Project Courage. I am satisfied that I completely understand my rights as a client of Project Courage.

Project Courage Client:

Print Name: ________________________Signature:_________________________ Date: __________




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Responsibilities To read this document in its entirety . Much of the information contained in this

document is vital to your treatment.

To be honest . You are responsible for being honest and direct about anything that relates to you as a client. This includes, but is not limited to, any assessment information you provide, session content you raise, and any feedback regarding selected interventions that your counselor requests of you.

To understand your treatment (action) plan . If you do not understand your treatment plan ask your Primary Clinician. Be sure you understand your action plan because this will be critical to the success of your action plan.

To follow the treatment (action) plan . It is your responsibility to discuss with your Primary Clinician whether or not you think you will want or be able to follow your action plan. When we consider if our clients are making progress in their treatment at Project Courage we use the following indicators: results of toxicology screens, attendance and tardiness, your willingness to allow other important individuals into your treatment, if your becoming more ready to change, how involved your family members are in your treatment (assuming you’ve given consent for this), if your taking medications as prescribed, and if you have—or are working towards—developing a healthy structured schedule for your daily life.

To keep appointments and be on time to appointments . You are responsible for keeping AND making your appointments. Do not anticipate that we will call to arrange for an appointment with you (further elaboration on this is discussed in our financial agreement.)

To provide your counselor with access to information that will allow for appropriate care. Allowing your Primary Clinician to talk with other important individuals in your life will enhance treatment. Additionally, the review of existing records can enhance service delivery and produce a more efficient treatment process. Thus, at times, it may prove beneficial to have access to sources such as schools, parents, spouses, officials of the judicial system, etc.

To respect the privacy of others . When you enter the PROJECT COURAGE building (waiting area, group room, etc.), other individuals may be awaiting services. Please be respectful of their confidentiality by not sharing this information with others.




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To treat your Project Courage staff with respect . Sexual, physical, and/or verbal harassment will not be tolerated.

To treat the building with respect. If you break or destroy something you will be responsible to pay for it (the cost or expenditure will be added to your treatment bill, which most likely will be paid by the individual financing your treatment).

To take responsibility for personal possessions. We will not reimburse you for lost or stolen items

To take responsibility for medications prescribed to you by a licensed health care professional. You may use prescription medications only under the supervision of a licensed healthcare professional and in strict conformance with the prescription. Appropriate documentation stating such from the prescribing healthcare professional will be required PRIOR to your initiation of treatment at PROJECT COURAGE. Additionally, any modification or deviation will require an order signed by the prescribing health care professional.

To know and understand the program rules and regulations . (see following section)

To know, understand follow all emergency procedures and evacuate during drills .

Program RulesLearning to accept direction and individual responsibility are vital components of the recovery process. In this manner, we view the enforcement of our program rules as a therapeutic means rather than a punitive one. We will do our best to work with you and understand that the enforcement of disciplinary measures is stressful for both the client and staff. However, if your continued presence in the program will jeopardize the treatment of other patients or yourself, we will consider a noncompliant discharge.

As such, PROJECT COURAGE has the right to discharge a client who has become a behavioral problem, is noncompliant with facility rules, or violates specific rules related to possession or use of unauthorized substances, stealing, sexually acting out, violence or threats of such. The person responsible for bringing or referring you to PROJECT COURAGE will be notified of this action.

If you are discharged from our program because of noncompliance, than you may not continue to participate in group therapy, individual therapy, consultation or any other service provided by PROJECT COURAGE. Your therapist will offer a referral deemed appropriate by our staff and will assist you in following through on this.

Rules of conduct1. Do not have in your possession any mood altering chemicals and report any violations of

this rule to a staff member. The rules of the streets do not apply at PROJECT




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COURAGE; do not put yourself or others in harm’s way by withholding such information.

2. The following may be grounds for immediate noncompliant discharge: Possession or use of mood altering chemicals. Fighting. Sexual activity. Regularly engaging in: acts of intimidation, seductive behavior, destruction or

disrespect of property, abusive language and behavior toward peers or staff, or the ignoring of your treatment plan.

No sleeping during groups, individual sessions, psychoeducation sessions, etc. Do not work on school assignments in group individual sessions, psychoeducation

sessions, etc. No electronics (cell phones, i-pods, etc.) in group therapy, individual sessions,

psychoeducation sessions, etc. No horseplay/roughhousing. No stealing. No gambling. No sexually explicit material (pornography). No cross talking or side conversations in groups. Do not leave group or individual sessions unless you absolutely have to (bathroom

breaks are available before, in-between, and after groups). No unauthorized absences from group or individual counseling. No selling, lending, or borrowing personal items to/from other clients. No drug or sex talk (war stories). No smoking outside designated areas. No chewing tobacco in groups. No cigarette butts outside of designated receptacles. Do not leave the premises without staff permission. No medications, aerosol cans, perfumes and colognes, mouthwash, hairspray, musical

instruments (unless previously authorized), razors, knives or any weapon of any sort. If you leave the program prematurely (against medical or clinical device) PROJECT

COURAGE has the right and obligation to inform your emergency contact of your decision and method of leaving.

Confidentiality of other clients must be upheld at all times. This means not releasing any information about another client without that client's permission. Violation of another person's rights or privacy can be grounds for discharge from the program.

In the event that the presence of substances or the use of substances is known or suspected to have occurred, PROJECT COURAGE reserves the right to search clients and their belongings at any time. All such searches will be conducted as deemed appropriate. Additionally, PROJECT COURAGE staff has a right to administer random toxicology screens to detect potential substance use. This includes random urine screens, hair follicle screens, saliva screens, and breathalyzer testing. By signing this agreement, you are authorizing PROJECT COURAGE to drug test you (the client) and to bill your insurance company if applicable.




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Staff Initial ________ Client Initial _________




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Part V:PROJECT COURAGE Electronic Communications Policy.

Use of provider-client email can facilitate and improve communication between the individual and the provider. However, there are some inherent risks involved in doing so. In order to minimize any potential compromises to your privacy please be informed of the following:

Email should be used for convenience. In instances of emergency or time-sensitive issues, use of the telephone is preferred.

Use care in what you email. Only basic information should be communicated. We will limit personal health information to the minimum necessary to meet the needs of our communication.

We will check my email once a day. If your email is regarding an appointment, this information will be shared with our office

manager. This individual understands the sensitive nature of your personal information and is mandated to uphold the same strict confidentiality stipulations that the therapists do.

Each email will contain a notation regarding the sensitive and confidential nature of its contents.

Those emails containing only minimal privacy-related information such as appointment booking or reminders of services will make use of insecure electronic messaging and will be considered temporary communications, and as such they will be discarded routinely. However, should the content of an email contain material that is clinically relevant, the email may be made part of the client’s records and as such be retained pursuant to PROJECT COURAGE’s health record retention schedule.

While we cannot guarantee the absolute security and privacy of your electronic information, we will take real precautions that are equal to or exceed those that are applied to written documents and records, such as:

Prevention of unauthorized access and use of the computer or any of the materials contained on it.

We will use only one backup source of the material contained on my computer. Restriction of shared information via signed release for information. We will not release

any identifying information about you to any third party(s) under any circumstances for any reason unless you have signed a release of information allowing us to do so, or if we are being mandated by to do so via subpoena. In some limited cases (i.e. appointment setting) some of this information may be shared with the office manager. Such information will be limited in scope and will ONLY reveal necessary scheduling information.

We will monitor all access to this computer on a regular basis to the best of my ability to ensure there has been no unauthorized access.

We will employ practical security measures to provide real security for your electronic information including the use of a firewall, and antivirus software. All computers will




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have both a screensaver password and log on password. If you would like, it is possible to additionally safeguard your data using data encryption procedures. In order to do this we will both need to use data encrypting software. If you wish to do this please inform the director.

If there is a breech in security or if there has been unauthorized access of my computer we will let you know of such an instance in writing or by phone.




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Part VI:PROJECT COURAGE Grievance Procedure

If you have complaints or are having problems in treatment please initially address these with your counselor. If you feel this complaint is important and you also feel that it has not been addressed by staff a more formal process is available to you. At this point, the next step is to schedule an appointment with the Executive Director of PROJECT COURAGE. You also need to put your concerns in writing. In order to do this use the PROJECT COURAGE Grievance Form located on the following page (additional copies can be made and area available from our Office Manager. Give this completed form to the Executive Director and he/she will notify of its receipt and what follow up actions will occur. You also have the right to report any complaint about our services to the state licensure board that regulates our practice at the Connecticut Department of Public Health 860-509-7603.




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Grievance FormA documented grievance process is employed to allow any of the staff members or clients of PROJECT COURAGE to submit a formal complaint for the handling of their clinical care, program or staff issue, financial matters, confidentiality, etc. This process ensures that both staff and client rights are maintained and affords the opportunity for an objective review and resolution of such complaints. The submission of any complaint will not result in retaliation, barriers to services, or loss of privileges. The completion and delivery of this form to appropriate staff members should occur within 72 hours of the incident. If you need help completing this form, please ask.

1. Name the person filing complaint:_______________________________________________

2. Relationship to the organization (client, family member, staff, etc.)___________________________________________________________________________________________________

3. Individual or department involved:_______________________________________________

4. Date of the event/incident______________________________________________________5. Description or nature of issue (please continue on back if necessary):_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Do you request a response? yes no7. Phone number and address___________________________________________________________________________________________________________________________________8. What action would you like to request as result of this?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________9. Signature_________________________________________

If you have requested a response we will provide a written response to you within seven working days of receipt of this form. We may request additional information from you and our response will include the efforts and/or actions made to resolve your complaint.

Just as the confidentiality of our clients is paramount, so is the confidentiality of our employees. Any employee disciplinary action will be handled in accordance with personnel policies and will not be included in any response.




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Part VII:Additional Policies Not Discussed Elsewhere

All other existing polices not hereto mentioned will be covered in this section.

Crisis ManagementFor the purposes of this policy, a crisis is defined as when an individual is seriously considering or has decided to hurt themselves or someone else.

In general staff are available during normal business hours. When the matter is urgent BUT NOT a crisis please call and if we are unavailable please leave a message. We check our messages throughout the word day. For urgent matters we will make every effort to return your call within 24 hours from the time we receive your message, however no guarantees can be made. When you are meeting with your counselor please make arrangements with them regarding their phone availability. When your practitioner is away from the office for an extended period, such as at a training or on vacation, you may leave a voice-mail but please know the response time will be extended.

If you or the individual receiving services from PROJECT COURAGE is in a crisis, please make use of the following steps:

Here are the steps for dealing with a crisis: 1. If the crisis is imminent you must call 911.2. If you believe there is enough time, you can call a mobile crisis unit:

You simply need to dial 211 to call the Connecticut Infoline. This service is available 24 hours a day, 7 days a week, 365 days a year. 211 is anonymous and will either refer you to an appropriate service or provide you with a crisis worker.

3. Call PROJECT COURAGE after you have employed step 1 or 2 above. If you get our voice mail leave a detailed message indicating what has happened and where we can reach you.

Goal SettingWhen individuals enter treatment they often desire certain results. There are often significant others who also are hopeful for certain goals to be accomplished. Finally, the practitioner may feel a particular outcome will be best suited for the individual receiving services. Usually, there is cohesion between each of these goal sets. Unfortunately at times there is not. We will work to achieve consensus regarding treatment goals. This may include the recommendation of a goal by the practitioner. However, when a triangulation of goals occurs please know that it is the individual receiving services whose goals need to be primary, except when to do so would result in injury to themselves or others.

Working with your Primary Care Physician or PediatricianWhether you are an adult or a child/adolescent we request that you inform your general practitioner that you will be receiving services from PROJECT COURAGE. It is important to meet with your doctor and have a blood screen administered to rule out the impact of any physiological conditions on your mental health. Additionally, your doctor may be able to provide needed insight and expertise, and make referrals for needed services such as a neurological exam.




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For Divorced Parents of a Child Receiving ServicesIn order to best serve your child it is imperative that both biological parents are aware that your child is receiving counseling from PROJECT COURAGE. Thus, if you are bringing your son/daughter to PROJECT COURAGE please inform his/her other parent that you are doing so. In rare instances such as the threat of physical abuse and/or substance abuse issues from the other parent the enactment of this policy may be postponed.

Please have payment ready at the beginning of each session. If both you and the other parent are responsible for healthcare costs please determine who will be responsible for payment prior to engaging in treatment, and make arrangement to have the payment ready at the beginning of each session. Failure to do so will result in billing and collections procedures as detailed in the financial agreement.

Emphasis on CollaborationAs detailed in Part I PROJECT COURAGE makes use of systems theory. As such, it is essential that collaboration occur between the practitioner and the different systems in the individual’s life. Please do not misunderstand, we will hold the protection of your privacy to the highest standards. However, we also want to offer you the most efficient and effective service delivery. Please be willing to allow us to contact individuals who play a significant role in your life. Examples include family members/parents, other providers (doctors, specialists, etc.), representatives from your school system, and representatives from the judicial system. Please know that ultimately this is your decision and in order to talk with any individuals a release of information form must be signed. Finally, if you do decide to let us speak with individuals pertinent in your life please do not expect us to withhold any information or be dishonest with any of these individuals.

Use of SpiritualitySpirituality and spiritual concepts ought not be confused with religion. For our purposes we define spirituality as a way of finding meaning, hope, comfort, and inner peace in your life. For some, these things are fulfilled through religion, however others may employ other avenues such as music, art, a connection with nature, or living by values. Some research suggests that the strength and comfort gained from prayer, meditation, and/or religion can contribute to healing. Historically in our culture the fields of mental health and spirituality have not intersected. Recently however, this seems to be changing. At PROJECT COURAGE we may employ spiritual principles or techniques to try and promote your mental health. However, if you feel this would be detrimental to your progress we will respect this. Please provide us with honest and accurate feedback so we can be respectful of your preferences regarding spirituality.




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Sign-off Sheet

All Inclusive: PROJECT COURAGEI (We) certify that I (we) have received a copy of, read, understand and agree to the conditions as described in the above document in its entirety.

Person(s) receiving services: Print Sign Date

and/or Parent(s) or guardian(s): Print Sign Date

Print Sign Date

For Office Use Only

I attempted to obtain written acknowledgement of receipt of our Welcome Packet detailing agency policies. Acknowledgement could not be obtained because:

Individual refused to signCommunications barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (Please Specify):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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