ORIENTATION SIGNATURE CHECKLIST

Name: Date Of Birth:

Please check the topics your care provider reviewed with you.
I was introduced to Jireh and the Services.
I was informed of Jireh’s, the assessors’ and the treatment teams’ qualifications to provide the services.
The purpose and process of the assessment was fully explained to me.
My family understands how our treatment plan will be developed.
My family and I were encouraged to participate in my treatment planning.
My consumer rights were explained and a copy given to me.
The grievance and appeals procedures were explained and a copy given to me.
Jireh provided me with Privacy Practices Notice
I received program Consumer Orientation Brochure on my initial visit which includes mission statement,
Hours of Operations, After Hours access, policy on abuse, complaints and grievance procedures, outcomes
management system and satisfaction, reporting, medication, open door policy, restraints/seclusions,
smoking policy, weapons, illegal/legal drugs, Treatment Team, Service Coordination, Costs of Services,
Safety and Advanced Directives
Information was presented to me in a manner that was clear and understandable.
My care program, treatment team visits and treatment responsibility were fully explained to me.
I understand that crisis services will be used for emergencies only.
The criteria for transition of my families’ service were explained to me.
Costs of Services
I know how my services are being paid for.
I understand that it is my responsibility to inform Jireh of any changes in my insurance coverage.
No individual will be denied MRO service because of verified inability to pay, you may be referred to other
resources.
Jireh Counseling and Consulting Service does reserve the right to refuse services to any individual who is
determined to be able to pay but is unwilling to pay according to policy.
Consumer Certification
I certify that all information given to JCCS is a true and complete statement of my financial circumstances,
and that the fees to be charged to me have been explained to me. I understand and accept responsibility
for my share of the cost of my treatment. My signature below gives Jireh Counseling and Consulting
Service, Inc. the authority to bill and receive payment from any third party Insurance. I understand that I
am responsible for any deductibles and/or co-payments and that payment is expected at the point of
service.
Assignment of Rights: I hereby authorize Jireh Counseling and Consulting Service to carry forward an
appeal on my behalf, should they so choose, as permitted by law. I understand that this does not obligate
or require Jireh Counseling and Consulting Service to carry forward any such appeal, unless they so
choose.
I acknowledge that JCCS honors Advanced Directives whenever clinically practicable and will provide me
with a referral for legal assistance if requested. Do you have an existing Advanced Directive?
[]yes []no
Follow Up
I feel that my visit was held in a private and confidential setting.
I know who is responsible for my service coordination.
I KNOW WHAT HAPPENS NEXT
Signatures

Signature of Consumer/Representative* Date Signed Signature of Care Provider

Relationship
*Parent/legal guardian’s signature in the case of a minor or custodian’s signature in the case of an adult in custodial
care.

BH 902-Orientation Signature Checklist Est. Mar 08

 Consent to Treatment

I do hereby seek and consent to take part in the treatment provided by this agency. I
understand that developing a treatment plan with this therapist/team and regularly
reviewing our work toward the treatment goals are in my best interest. I agree to play an
active role in this process. I understand that no promises have been made to me as to
the results of treatment or of any procedures provided by this therapist/team.

I am aware that I (or my child) may stop treatment with this therapist/team at any time. I
understand that I may lose other services or may have to deal with other problems if I
stop treatment. (For example, if my treatment has been court-ordered, I will have to
answer to the court.) I know that I must call to cancel an appointment at least 24 hours
before the time of the appointment or as soon as reasonably possible.

I am aware that an agent of my insurance company or other third-party may be given

information about the type (s), cost (s), and providers of any services I receive.

My signature below shows that I understand and agree with all of these statements.

___________________________________ _______________
Print Name of Consumer Date

___________________________________ _______________
Signature of Consumer Date
(or person acting for consumer)

______________________________________
Relationship of Person Acting for Consumer

I, the therapist, have discussed the issues above with the consumer/family (and/or his or
her parent, guardian, or other representative). My observations of this person’s behavior
and responses give me no reason to believe that this person(s) is not fully competent to
give informed and willing consent.

__________________________________ ________________
Signature/Title/Credentials Date

CR101—Consent to Treatment Est. Mar 08

 Your Rights as a Consumer
Of Jireh Counseling and Consulting Services
Mental Health, Developmental Disabilities, and Addictive Diseases

State and Federal laws protect your rights as a consumer of Jireh Counseling and Consulting Services treatment
programs. Below is a simplified outline of those rights:

Your rights include:

• The right to receive care suited to your needs.

• The right to receive services that respect your dignity and protect you health.

• The right to pertinent information, including the benefits and risks of your treatment, in sufficient time
to make informed decisions.

• The right to participate in planning your own program, and the right to request choice over the
composition of the service delivery team.

• The right to refuse service, unless a physician or licensed psychologist feels that refusal would be
unsafe for you and others.

• The right of referral to legal entities for appropriate representation, and to self-help and advocacy
support services.

• The right to prompt and confidential services even if you are unable to pay.

• The right to request an opportunity to inspect, copy, and correct your records).

• The right to exercise all civil, political, personal, privacy and property rights to which you are entitled
to as a citizen.

• The right to remain free of physical restraints or time-out procedures unless such measures are
required for providing effective treatment or for protecting your safety or the safety of others.

• The right to be free of physical abuse, including sexual abuse, and physical punishment.

• The right to remain free of psychological abuse, including humiliating, threatening, and exploiting
actions.

• The right to file a complaint if you think any of these rights have been restricted or denied.
Information on how to file a complaint or contact your Consumer's Rights Representatives is
presented on a poster near the reception desk.

CR100—Consumer Rights RevOct 08

 Consumer Rights and Responsibilities

Consumer Receipt & Acknowledgement of Rights:

My signature below certifies that I have read AND understand completely what my rights are as a participant in
Jireh Counseling And Consulting Services, Inc. program.

___________________________ ______________
Consumer Signature Date

___________________________
Consumer Name (Print)

____________________________ _____________
Staff Witness Date

CR100—Consumer Rights RevOct 08

 GRIEVANCE PROCESS
Consumer’s Name: DOB:

Jireh values the involvement of members in the organization and functioning of the agency. As a Jireh Counseling and
Consulting Services, Inc. consumer you have a right to register formal complaints about specific issues relating to the
general operation and management of the agency. You also have additional rights to appeal decisions regarding the
planning and delivery of the individualized services you receive from the agency. Filing a formal grievance or appealing a
decision regarding your services will never result in any retaliation or barriers to services.
These are the steps you should follow if you are dissatisfied with any aspect of the general operation and management of
the agency or if you wish to appeal decisions regarding the planning and delivery of individual services:
STEP Talk about the problem right away with your counselor. Try to resolve the problem. Most concerns can be
resolved by just talking it over with the responsible staff members.

STEP If you feel that your concern was not resolved to your satisfaction after STEP ONE, you may file a formal
grievance with your program's supervisor. The program supervisor must respond to your request in writing
within five working days.

STEP If you feel that your concern was not resolved to your satisfaction after STEP TWO, you may file a
complaint with the Clients Right Officer. They will help you document your concern in writing and will
investigate it by meeting with the individuals involved and reviewing any related records. The CRO will
provide a written response to your request within five working days following the meeting. At your request,
they will also give you information about external agencies that provide advocacy and/or legal services in
the community.
STEP If you feel that your concern was not resolved to your satisfaction after STEP THREE, you may request a
review of the decision by the CEO. The CEO will meet with you within ten working days following your
request. They will investigate and document your concern and issue a decision, in writing, to you within ten
working days following the meeting with you. Decisions by the CEO are final. The only exceptions are for
appeals of individual services such as denial of services (i.e. program suspensions), changes in service
plans or refusals to change service plans and/or termination from service. In these cases there is one more
step you may take.
STEP If your concern is about the specific services you receive at Jireh Counseling and Consulting Services, Inc.
and involve:
¾ denial of services
¾ change of service plan
¾ refusal to change service plan
¾ termination from services
You have a right to appeal the CEO decision (STEP FOUR) to

Office of Regulatory Services, ORS.

Complaint Intake Unit,
2 Peachtree Street, Atlanta, GA 30303
Telephone (404) 657-5726

BH103(b)—Consumer Grievances Rev Oct2008

 Consumer Grievance/Complaint Form

COMPLAINTANT
Name:
Address: Phone #:
Case Manager:
Program:
DETAILS
Problem/Grievance/Complaint (List of who, what, when, where, why, etc.):

What do you think needs to be done to solve this problem? What do you expect to do to solve your problem?
What is the relief you desire?

Who have you talked to about this problem?

Additional Remarks:

SIGNATURES

Cient Signature Name (print) Date

Received By (JCCS Staff member) Name (print) Date

BH104(b)—Consumer Grievances EstNovt2007

 GRIEVANCE PROCESS
Consumer’s Name: DOB:

Consumer Grievance Policy Receipt & Acknowledgement

Signature Page

My signature below certifies that I have read AND understand completely what the grievance
procedures are as a participant in JIREH COUNSELING AND CONSULTING SERVICES, INC.
program.

I have received a copy of the Grievance Form

__________________________ ______________
Client Signature Date

__________________________
Client Name (Print)

_________________________ _____________
Staff Witness Date

BH103(b)—Consumer Grievances Rev Oct2008

 NOTICE OF PRIVACY
PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY
Your health record contains personal information about you and your health. This information about you
that may identify you and that relates to your past, present or future physical or mental health or condition
and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy
Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW
Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and
privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy
Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new
Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with
a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in
the mail upon request or providing one to you at your next appointment.
How We May Use and Disclose Health Information about You
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of
providing, coordinating, or managing your health care treatment and related services. This includes consultation with
clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your
authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to
you. This will only be done with your authorization. Examples of payment-related activities are: making a
determination of eligibility or coverage for insurance benefits, processing claims with your insurance company,
reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it
becomes necessary to use collection processes due to lack of payment for services, we will only disclose the
minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business
activities including, but not limited to, quality assessment activities, employee review activities, licensing, and
conducting or arranging for other business activities. For example, we may share your PHI with third parties that
perform various business activities (e.g., billing or typing services) provided we have a written contract with the
business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be
disclosed only with your authorization.

Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we
must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of
investigating or determining our compliance with the requirements of the Privacy Rule.

You should determine which of these uses and disclosures are permitted in your state for the type of information that
you will be using or disclosing.

The following language addresses these categories to the extent consistent with the NASW Code of Ethics.

CR103—HIPPA Notice EstMAR08

 NOTICE OF PRIVACY
PRACTICES
Without Authorization. Applicable law and ethical standards permit us to disclose information about you without
your authorization only in a limited number of other situations. The types of uses and disclosures that may be made
without your authorization are those that are:
• Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory
government agency audits or investigations (such as the social work licensing board or the health
department)
• Required by Court Order
• Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or
the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a
person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission
We may use or disclose your information to family members that are directly involved in your treatment with your
verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your
written authorization, which may be revoked.

Your Rights Regarding Your PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit
your request in writing to our Consumer Rights Officer at 5522-C Old National Highway, Suite A, College Park GA,
30349 404 761 0980.
• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional
circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to
inspect and copy PHI will be restricted only in those situations where there is compelling evidence that
access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.
• Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to
amend the information although we are not required to agree to the amendment.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the
disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one
accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or
disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to
your request.
• Right to Request Confidential Communication. You have the right to request that we communicate with
you about medical matters in a certain way or at a certain location.
• Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy
Officer at Jireh Counseling & Consulting Services, Inc. at 5522-C Old National Hwy, Ste. A, College Park, GA
30349, or with the Office of Regulatory Services, ORS, Complaint Intake Unit, 2 Peachtree Street, Atlanta, GA 30303
-Telephone (404) 657-5726. We will not retaliate against you for filing a complaint.

The effective date of this Notice is June 11, 2007.

CR103—HIPPA Notice EstMAR08

 NOTICE OF PRIVACY
PRACTICES

RECEIPT AND ACKNOWLEDGEMENT OF HIPPA NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Jireh
Counseling & Consulting Services, Inc. Notice of Privacy Practices.

I understand that if I have any questions regarding the Notice or my Privacy Rights, I can contact the Chief
Executive Officer, Felicia Jenkins, or Administrator of Jireh Counseling & Consulting Services, Inc. at 5522-C
Old National Hwy, Ste. A, College Park, GA 30349 at 404-761-0980 or, or the Metro Regional Office for the
Department of Health and Human Services (DHR).
.
____________________________________________________ ___________________________
Signature of Consumer, Parent, Please Print Name
Guardian or Representative

PLEASE READ: If you are signing as a personal representative of the consumer, please describe your legal
authority to act for the consumer or the consumer’s legal guardian (power of attorney, healthcare surrogate, legal
guardian, parent)

______________________________________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Signature of Staff Member_______________________________ Date:_____________________

ONLY IF CONSUMER OR GUARDIAN REFUSES TO SIGN COMPLETE BELOW

Date: __________________________

Please check here if the following applies:

Consumer / Guardian or legal representative refuses to sign:

Signature of Staff Member__________________ Date:_____________________

CR103—HIPPA Notice EstMAR08

 Authorization Request
I AUTHORIZE JIREH COUNSELING & CONSULTING SERVICES, INC., ITS AGENTS AND ITS EMPLOYEES (JCCS) TO RELEASE/OBTAIN PROTECTED HEALTH
INFORMATION (PHI) ABOUT ME /MY CHILD TO/FROM THE RECIPIENT; FOR THE PURPOSES, AND UNDER THE CONDITIONS DESIGNATED ON THIS FORM.

PATIENT RECIPIENT

Name

Address

City State Zip

Date Of Birth Phone Number City State Zip

Description of Information to be disclosed: (Guardian should check each item to be disclosed and sign the bottom of form)
Diagnostic Assessment Treatment Plan or Summary Educational Information
Psychosocial Evaluation Presence/Participation in Treatment Demographic Information
Psychological Evaluation Progress in Treatment Toxicological Reports/Drug Screens
Psychiatric Evaluation Current Treatment Update Other
Nursing/Medical Information Discharge/Transfer Summary Other
Medication Management Information Continuing Care Plan

Purpose
The purpose of this disclosure of information is to improve assessment and treatment planning, share information relevant to treatment and when appropriate,
coordinate treatment services.
If other purpose, please specify:

Please send information requested to:

JIREH COUNSELING AND CONSULTING SERVICES, INC.
5522-C OLD NATIONAL HIGHWAY, SUITE A
COLLEGE, PARK GA 30349
Phone: (404) 761-0980 Fax Form To: (404) 761-0720
EXPIRATION
Unless sooner revoked, this consent expires ONE YEAR FROM THE DATE OF SIGNATURE
REVOCATION, DISCLOSURE
I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Jireh Counseling & Consulting Services,
Inc. at 5522 Old National Hwy, Ste. A, College Park, GA 30349. I further understand that a revocation of the authorization is not effective to the extent that
action has been taken in reliance on the authorization.. FORM OF DISCLOSURE .Unless you have specifically requested in writing that the disclosure be made
in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent
with applicable law, including, but not limited to, verbally, in paper format or electronically RE-DISCLOSURE Federal law prohibits the person or organization to
whom disclosure is made from making any further disclosure of substance abuse treatment information unless further disclosure is expressly permitted by the
written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. Other types of information may be re-disclosed by the
recipient of the information in the following circumstances: Medical or life threatening emergency
CONDITIONS OF ELIGIBILITY
I further understand that Jireh Counseling and Consulting Services, Inc. will not condition my treatment on whether I give authorization for the requested
disclosure. However, it has been explained to me that failure to sign this authorization may have the following consequences:
If services are hindered, clinicians are prevented from properly advocating or acting in the client’s best interest, or a danger is created due to the clients
refusal to sign authorization then Jireh Counseling & Consulting Services, Inc. may choose not to continue services to client.
SIGNATURES (If signing as a personal representative of an individual, describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.).
I will be given a copy of this authorization for my records:

Signature of Parent, Guardian or Personal Representative Relationship Date

Patient/client refuses to sign authorization

Signature of Staff witnessing all of the above Date

CR701-Authorization to Release PHI

 Consent to Publication of
Photographs and Film

Please have the consumer complete this consent statement, and then place it in
the consumer’s clinical record under the administrative tab.

I, _______________________________ of _____________________________
(Parent/Guardian or Legal Representative name) (Consumer Name),

hereby consent to being photographed and filmed while attending programs at

or with the staff of Jireh Counseling and Consulting Services(JCCS). I further
consent to the publication and / or public display of these photographs or film for
the purposes of celebrating consumer achievements, consumer advocacy and /
or raising awareness of the services provided by JCCS.

I also consent to the publication of my name alongside the images.*

*Initial if applicable [ ]

This consent is valid for a period of one year from the date of signing. I have the
right to withdraw this consent to further photography, filming or publication at any
point, save only those images already published under this consent that cannot
be reasonably withdrawn.

_____________________________________________ _________________
CONSUMER SIGNATURE DATE

IF APPLICABLE:

_____________________________________________ _________________
SIGNATURE OF REPRESENTATIVE DATE

_____________________________________________
RELATIONSHIP TO CONSUMER
A REPRESENTATIVE SHOULD DESCRIBE HERE THEIR AUTHORITY TO ACT FOR THE
CONSUMER (E.G., LEGAL GUARDIAN,PARENT OF MINOR CHILD)

BH2200—Consent to Publication of Photography, Video and Audiotape EstMAR2008

 Transportation Authorization Form

1. Staff Name: ___________________________

GA Driver License Number: _________________ Exp. Date___________

Name of Insurance Company__________________________ Policy # ______________

2. Staff Name: ___________________________

GA Driver License Number: _________________ Exp. Date___________

Name of Insurance Company__________________________ Policy # ______________

3. Staff Name: ___________________________

GA Driver License Number: _________________ Exp. Date___________

Name of Insurance Company__________________________ Policy # ______________

The above referenced staff member(s) are authorized to use their personal vehicle to
transport _________________________________________ for the following reason(s):
(Consumer/Family Member)
during the course of treatment.

___ Medical Related ____ Legal and Court Related Activities

___ Educational Related ____ Other: _____________________________

I acknowledge that transportation is voluntary and during transportation the staff member
will not knowingly or intentionally place me and/or my child(ren) in danger. The staff
member has my permission to notify or seek emergency assistance if unforeseen
circumstances occur if I am not present that may require any such public emergency
official services. My signature below signifies that I agree and release the staff person(s)
and the agency from all liability and cost related to transport services.

_________________________________ _________________________
Parent / Legal Guardian Signature Date

BH3501—Transportation Consent Rev Oct2008

We constantly seek to improve our services, so it is important
to us to hear from you about any areas of weakness that
could be improved. This leaflet explains some of your rights
as a consumer, what to do if your rights are violated, and in
addition provides some important information for your welfare
and safety while receiving services from us.
Abuse and Sexual Activity
You have the right to be free of physical abuse, including
sexual abuse and physical punishment. No staff member
should abuse any consumer through physical or verbal
attack, exploitation, or coercion. No staff member should
engage in any sort of sexual activity with any consumer, or
allow sexual activity between or among consumers while the
consumers remain under the care or supervision of Jireh
Counseling and Consulting Services, Inc (JCCS).
If you experience or witness any form of abuse or sexual
activity, please report it to a member of staff such as those
listed on the consumer rights notices posted in the office. All
reports of abuse go to the Consumer Rights Officer. The
CRO will investigate the incident (names of this person is
located on posters displayed at the service location).
The CRO will assist you in making a complaint if you wish
(see next section). If the CEO has reasonable cause to
believe that the incident constitutes criminal conduct, she will
report the incident to the appropriate law enforcement
agency.
A staff member who is found to have committed abuse will be
subject to disciplinary action in accordance with personnel
procedures of the board.
If a staff member has reasonable cause to believe that a
parent of caretaker of a minor has inflicted physical injuries
other than by accident, has neglected, exploited sexually or
assaulted the child, then the staff member shall notify the
executive director or her designee who in turn shall report the
allegation to the appropriate County Department of Family
and Children Services. We are required by law to report all
abuse and neglect of adult consumers in accordance with the
provisions of O.C.G.A. 30-5-1--30-5-8.
Complaints and Grievances
All complaints/grievances should be filed with the Program
Supervisor. The name and contact information for the
Program supervisor is listed on the back of this brochure and
on the crisis calendar. A complaint form is available on
request. Complaints may be made in person or by telephone.
The Supervisor will assist you in making a complaint if you
wish, and will provide you with all the necessary information
about complaint and appeal procedures. In brief, these
procedures are as follows:
As soon as possible, but within 5 working days after your
complaint is filed, the Program Supervisor will investigate the
complaint and interview those involved as necessary. The
Supervisor will attempt to resolve the complaint through
BH905—Consumer Orientation Brochure
mediation and conciliation whenever possible. A complaint
may be rejected if there is no evidence to support it or if the
Supervisor finds that the alleged conduct does not in fact
violate your rights. The Supervisor will report to you in
writing, to let you know the decision.
If your complaint is rejected or is not resolved by the
Supervisor to your satisfaction (or your guardian or parent if
you are a child), you may request a review of the decision by
writing to the Consumer Rights Officer within 15 days. The
CRO should complete his / her review in a timely manner and
report back to you in writing within 5 days. If you are not
satisfied with the outcome of the CRO’s review, you (or your
parent or guardian) may request a further review by the CEO
by filing a written appeal within 10 days of notification of
rejection notice or other decision. Within 5 working days of
the filing of your appeal, the CEO or his/her designee shall
issue a decision disposing of the appeal.
The CEO may affirm, reverse, or modify the CRO’s decision
or s/he may return the case to the CRO for further
proceedings. In no event shall the period for completing the
further proceedings exceed 5 working days. The decision of
the CEO is final. The CRO and the complainant shall be
notified of the decision.
General provisions are as follows:
1. Staff members who are involved in a complaint shall
not be involved in the processing of that complaint.
2. No person shall be subject to any form of discipline, or
reprisal solely because he has sought a remedy through or
participated in the procedure outlined in this section.
3. Obstruction of the investigation or disposition of a
complaint by any person shall report to the JCCS CEO
or designee, who shall take action to eliminate the
obstruction. Staff members are subject to adverse
action engaging in such obstruction, in accordance with
personnel procedures of JCCS.
4. Time limits designed in this Section may be extended by
the decision-maker at each step for good cause only.
Outcomes Management System and Satisfaction
As indicated within the Jireh mission as listed at the top of this
pamphlet, JCCS strives to provide a high level of quality services.
In order to continue to monitor the quality of services and
consistently improve services, JCCS has developed a quality
improvement process based on NIAtx Plan, Do, Study, Act.
Results are reviewed by a Performance Improvement Committee
then submitted to leadership.
Among the indicators is consumer satisfaction. Consumers are
given an intake satisfaction survey within their orientation packet
and are encouraged to complete it and return it to the designated
box. All JCCS staff have Consumer Satisfaction Surveys for
consumers to complete and provide feedback to the agency. All
surveys are forwarded to the Quality Improvement Officer quarterly
for result tabulation.
Confidentiality
Why we collect information and how we use it. We will
collect medical (health) information about you in order to
provide you with services that match your needs. We will use
and disclose that information in order to manage your health
care and treatment, to obtain reimbursement for treatment,
and to meet quality control and other government
requirements. We will not disclose any personal information
about you to anyone else without your prior approval and
consent, except as permitted or required by law.
Your Rights to Review and Correct Information. You have
the right to reasonably review and request corrections to
confidential and non-confidential information about you that is
held in our records.
Our Policies and Practices to Protect the Confidentiality and
Security of Information. We restrict access to personal
information about you to those who need to know that
information to provide services to you. All employees and
staff are required to comply with our established
confidentiality procedures and policies. We maintain
physical, electronic, and procedural safeguards that comply
with federal regulations to guard your personal information.
A full description of our privacy practices is contained in our
Privacy Practices Notice. You will receive a personal copy
(without charge) on request to the receptionist.
If you have any questions or concerns about the privacy of
your personal health information, or to complain if you believe
your rights or the rights of someone else have been violated,
please contact our Corporate Compliance Officer at 404-761-0720.
OR YOU MAY WRITE OR CALL - Office of Regulatory Services,
ORS, Complaint Intake Unit, 2 Peachtree Street, Atlanta, GA
30303 -Telephone (404) 657-5726
Medications
You have the right to know the benefits, side effects, and
risks of any psychotropic medication that may be prescribed
for you. The attending physician is responsible for assuring,
and documenting in your medical record that the benefits,
side effects, and risks of medications have been explained to
you and your family.
You or your parents or legal guardian will be asked to give
signed consent for the administration of all medications.
Open Door Policy
JCCS maintains an open door policy that guarantees access
to program leadership up to the CEO in person, in writing or
by telephone, or through e-mail.
Restraints/Seclusion
The use of personal restraints and seclusion by JCCS
personnel is prohibited.
Smoking/Tobacco Use
The use of tobacco in any form is prohibited in all JCCS
facilities. Tobacco use is also prohibited in staffs’ personal
vehicles during times when consumers are being transported.
There are designated smoking areas outside of the facility.
Est. Mar 08
 Weapons Hours of Operations
No weapons of any kind are allowed on JCCS property. Office Hours
Illegal/Legal Drugs Monday 8:30 AM – 6:00 PM
JCCS offers a drug free environment. Illegal drugs are Tuesday 8:30 AM – 6:00 PM
prohibited on any property owned leased or rented by the Wednesday 8:30 AM – 6:00 PM
agency. Legal drugs, including prescription and non-
prescription must be in original packaging identifying Thursday 8:30 AM – 6:00 PM
contents, recommended dosage, and frequency. Any Friday 8:30 AM – 6:00 PM
medications that will be housed on agency property will be 1st and 3rd Saturday 10:00 AM – 2:00 PM
placed in a secure area under close supervision.
Treatment Team
After Hours Access Consumer Orientation
Intensive Family Intervention
JCCS holds weekly multidisciplinary treatment team meetings to Information
develop consumer treatment plans review treatment progress JIREH EMERGENCY
modify levels of care and authorize consumer discharges. The
treatment team assessed appropriateness of treatment (404) 761-0980
interventions relative to consumer needs accuracy of assessment CORE Services – Community Support Individual
feedback from the consumer and significant others. The group is
Behavioral Health Link (SPOE)
reflective of the cultural diversity of the area population and
consumers served.
1-800-715-4225
Service Coordination
Medication Emergency-Poison Control
A service coordinator will be assigned at the point the intake
process is complete and treatment is authorized. (404) 616-0000
Cost of Services
My Treatment Team
It is the policy of JCCS that all consumers will be charged fees Name Phone Number
for services received according to the current rates in effect at
the time of service. A sliding fee scale may be applied to
charges based on the consumer’s, or family’s, verified income. ___________________________________________
No individual will be denied service because of verified inability to My Service Coordinator
pay. JCCS does reserve the right to refuse services to any
individual who is determined to be able to pay but is unwilling to
pay according to policy. ___________________________________________
Advanced Directives My Program Supervisor
JCCS will honor any advanced directives that you have made Our Mission
for your health care if they have been reviewed and approved ___________________________________________
by our Medical Director. If you wish to make such an Our mission is to create and deliver high
advanced directive, please submit it to your provider in the ___________________________________________ quality in-home, community-based, school-
first instance.
based, and out-patient mental health and
Safety
___________________________________________ substance abuse services that improves
Evacuation plans are located on maps hanging on walls. JCCS
Safety Code is as follows. the health and well being of children,
JIREH COUNSELING & CONSULTING SERVICES, INC.
Red...................................................................... Internal Disaster adolescents, and their families.
Blue .................................................................Medical emergency 5522-C Old National Highway, Suite A
Green ........................................... .Workplace threat and violence College Park, GA 30349
Gray....................................................................... Severe weather (404) 761-0720 (office)
Flashlights and first aid kits are located in the place that is (404) 761-0980 (fax)
indicated on the evacuation maps. Drills are conducted quarterly
provider@jirehcounseling.com
and consumers will participate in drills. Good hand washing is the
best way to prevent the spread of germs. Exit signs are located
at every exit.

BH905—Consumer Orientation Brochure Est. Mar 08