North South

3489 W 72nd Ave, Ste 105 4195 S. Broadway St.

Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

APPLICATION FOR ADMISSION

CLIENT #____________________
DOC # _____________________

NAME: ______________________________________________________ SEX M F  AGE: _______

LAST FIRST MI

ADDRESS_______________________________________________________________________________________________
STREET AND NUMBER CITY STATE COUNTY ZIP

TELEPHONE # ( ) _______________ WORK# ( ) _________________ CELL # ( ) __________________

PLACE A CHECK IN THE BOX WHERE MESSAGES CAN BE LEFT HOME  WORK CELL
IIIII
BIRTH DATE _______/________/________ PO E-MAIL ADDRESS ___________________________________________
IIIII
EMPLOYED: ■
YES  NO OCCUPATION: ________________________________________

EMERGENCY CONTACT: _____________________________________ RELATIONSHIP: ___________________________

PHONE: ____________________________
DO YOU CURRENTLY HAVE ADVANCED DIRECTIVES IN PLACE?  YES ■
 NO
WOULD YOU LIKE MORE INFORMATION ABOUT ADVANCED DIRECTIVES?  YES ■
 NO
DO YOU HAVE TRANSPORTATION TO/FROM TREATMENT? ■  YES  NO IF NO, CLIENT REFERRED FOR
TRANSPORTATION ASSISTANCE TO: _______________________________________________________________.
PREVIOUS ADMISSIONS TO CCR: __________________________________________________________________
CURRENT CHARGES & YEAR: _______________________________________________ BAC: ________________
PREVIOUS CHARGES & YEARS: ___________________________________________________________________

CURRENT OR PREVIOUS SUBSTANCE ABUSE TREATMENT: ________________________________________________

________________________________________________________________________________________________________

CURRENT OR PREVIOUS PSYCHOLOGICAL OR PSYCHIATRIC TREATMENT: _________________________________

________________________________________________________________________________________________________

REFERRAL SOURCE: (PO)_____________________________________ EVALUATOR: __________CASE # ____________

REFFERING COUNTY: _________________________________ PHONE: __________________ FAX: __________________

TREATMENT REQUIRED:  GROUP # _________ START DATE: __________LII-TX TRACK ___

 EVALUATION  SSIC _____ WEEKS  METH RECOVERY ______ WEEKS @ _____X/WEEK
 RELAPSE PREVENTION ______ WEEKS  OPIATE-SPECIFIC ______ WEEKS
 ANGER MANAGEMENT ______ WEEKS  THC-SPECIFIC ______ WEEKS
 CBT ______ WEEKS  CO-OCCURRING ______ WEEKS  OTHER _____________________
 RANDOM URINE TESTS ______X______ RANDOM BREATH TESTS ________ X __________

CLIENTS SIGNATURE: __________________________________________________________ DATE: _________________

STAFF SIGNATURE: ____________________________________________________________ DATE: _________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

DISCLOSURE STATMENT
Client Name: ___________________________________________________ D.O.B.__________________________

Counseling Center of the Rockies is a substance abuse treatment program licensed by the Office of Behavioral Health of
the Colorado Dept of Human Services. Your counselor is listed below:
 Jennifer Hodge, CACIII, Clinical Director
 Stephanie Rudell-Scrimo, LAC, NCC
 Tanya Crowder, CACIII
 Lillie Manzanares, CACII
 Paul Egan, CACII
 Liz Melo, LPC
 Craig Fiorini, CACII
 John Shannon, CACII
 Dawn Marsh, LPC
 Jennifer Cole, CACII

The practice of registered, certified, or licensed persons in the field of psychotherapy is regulated by and is the
responsibility of the Department of Regulatory Agencies (DORA). Questions and complaints regarding addiction
counselors may be addressed to:
Department of Regulatory Agencies, Mental Health Section
1560 Broadway, Ste 1350, Denver, CO 80202 (303) 894-7800

The Office of Behavioral Health has the general responsibility for regulating practices of licensed substance use disorder
treatment programs in the State of Colorado. Questions and complaints may be directed to:

Colorado Department of Human Services

Office of Behavioral Health
3824 W. Princeton Circle, Denver, CO 80236 (303) 866-7400

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

DISCLOSURE STATEMENT – CONT’D

1. The regulatory requirements applicable to mental health professionals are as follows:
 Registered psychotherapist is a psychotherapist listed in the State’s database and is authorized by law to
practice psychotherapy in Colorado, but is not licensed or certified by the State and is not required to satisfy
any standardized educational or testing requirements.
 Certified Addiction Counselor I (CAC I) must be a high school graduate or the equivalent, complete required
training hours and 1000 hours of clinically supervised work experience.
 Certified Addiction Counselor II (CAC II) must meet the CAC I requirements, complete additional training
hours above the CAC I, and 2000 hours of clinically supervised work experience.
 Certified Addiction Counselor III (CAC III) must have a Bachelor’s degree in the behavioral health sciences or
field; complete additional training above the CAC II, and 2000 hours of clinically supervised work experience.
 Licensed Addiction Counselor must have a clinical Master’s degree, meet the CAC III requirements, and pass
a national examination in addiction treatment.
 Licensed Social Worker must hold a master’s degree in social work.
 Psychologist Candidate, Marriage and Family Candidate, and a Licensed Professional Counselor Candidate
must hold the necessary licensing degree and be in the process of completing the required supervision for
licensure.
 Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, and a Licensed Professional
Counselor must hold a master’s degree in their profession and have two years of post-masters’ supervision.
 Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral
supervision.

2. You are entitled to receive information from your therapist about the methods of therapy, the techniques used, the
duration of your therapy (if known) and the fee structure. You can seek a second opinion from another therapist or
terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be
reported to the Board that registers, certifies or licenses the registrant, certificate holder or licensee.

3. Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and
cannot be released without the client’s consent. There are exceptions to this confidentiality, some of which are listed
in Section 12-43-218 of the Colorado Revised Statutes as well as other exceptions in Colorado and federal law. For
example, mental health professionals are required to report child abuse to authorities. If a legal exception to
confidentiality arises during therapy, if feasible, you will be informed accordingly.

4. I understand that my alcohol and/or drug treatment records are protected under the Federal Confidentiality
Regulation, 42 C. F. R., Part 2, governing Confidentiality of Alcohol and Drug Abuse Patient Records. Confidential
information cannot be disclosed without my written permission unless otherwise provided for by the regulations.

5. I have read the preceding information, it has been provided to me verbally, and I understand my rights as a client or
as the client’s responsible party. I agree to participate in treatment Counseling Center of the Rockies.

Client
Signature_________________________________________________________Date____________________________

Witness__________________________________________________________Date____________________________

If signed by someone other than the client, please sign and print name and state legal authority to sign for client.

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 TELEHEALTH EMERGENCY PLAN
While receiving behavioral health services remotely (telehealth) is convenient, it also has
limitations and risks. The therapist’s ability to respond to a medical or psychiatric emergency may
be impacted. Please complete this form to help inform your therapist’s creation of an emergency
plan to help reduce some of those risks.

Your name: _________________________________________________________________ _______

Address where your telehealth occurs: _____________

Telephone number where your telehealth occurs: _____________

Alternate phone number: _________________________________________________________________

Therapist’s location: __________________________ Telephone number: _________________________

A support person is someone who knows you are receiving therapy and is accessible to you
(nearby and willing to help) during your telehealth session. This support person could help in
case of emergency. Sign this form to allow your therapist to contact this person.
Support person name: _____________

Support person telephone number: ________________________________________________________

I give my consent for my therapist to contact my support person. I understand this means my
therapist may disclose private and confidential information. (Initial) _________

In case of a behavioral/medical emergency, the therapist will attempt to contact emergency services in
your local area. Emergencies might include expressing intent to harm yourself or another person, a
medical emergency, or any other condition requiring medical or psychiatric attention.

The therapist will try to maintain communication with you while he/she calls for help. This might
mean paramedics, mental health professionals, or local police will come to your home to make
sure you are safe and well. If appropriate, the therapist will also contact your support person.

In case of a technological videoconferencing failure, the therapist will contact you using the
telephone. In case of telephone failure (and without safety concern), the therapist will use secure
text messaging, email, or another agreed-upon communication platform.

Client signature: ________________________________________________ Date: ______________

Printed name: __________________________________________________

Copyright 2020 Between Sessions Resources

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

NOTICE OF FEDERAL REQUIREMENTS REGARDING

CONFIDENTIALITY OF ALCOHOL AND DRUG
ABUSE PATIENT RECORDS

FEDERAL LAW AND REGULATIONS PROTECT THE CONFIDENTIALITY

OF SUBSTANCE USE DISORDEWR PATIENT RECORDS MAINTAINED BY THIS
PROGRAM. GENERALLY, THE PROGRAM MAY NOT SAY TO A PERSON OR
ENTITY OUTSIDE THE PROGRAM THAT A PATIENT ATTENDS THE PROGRAM,
OR DISCLOSE ANY INFORMATION IDENTIFYING A PATIENT AS HAVING A
SUBSTANCE USE DISORDER UNLESS:

(1) THE PATIENT CONSENTS IN WRITING;

(2) THE DISCLOSURE IS ALLOWED BY A COURT ORDER;

(3) THE DISCLOSURE IS MADE TO MEDICAL

PERSONNEL IN A MEDICAL EMERGENCY OR TO
QUALIFIED PERSONNEL FOR RESEARCH, AUDIT, OR
PROGRAM EVALUATION.

VIOLATION OF THE LAW AND REGULATIONS BY A PROGRAM IS A CRIME.

SUSPECTED VIOLATIONS MAY BE REPORTED TO U.S. ATTORNEY BOB TROYER:
1801 CALIFORNIA ST, SUITE 1600, DENVER, CO 80202, PHONE: 303-454-0100.

FEDERAL LAW AND REGULATIONS DO NOT PROTECT ANY

INFORMATION ABOUT A CRIME COMMITED BY A PATIENT EITHER AT THE
PROGRAM OR AGAINST ANY PERSON WHO WORKS FOR THE PROGRAM OR
ABOUT ANY THREAT TO COMMIT SUCH A CRIME.

FEDERAL LAW AND REGULATIONS DO NOT PROTECT ANY

INFORMATION ABOUT SUSPECTED CHILD ABUSE OR NEGLECT FROM BEING
REPORTED UNDER STATE LAW TO APPROPRIATE STATE OR LOCAL
AUTHORITIES. (SEE 42 U.S.C.290dd-3 AND 42 U.S.C.290-EE-3 FOR FEDERAL
LAWS AND 42 CFR PART 2 FOR FEDERAL REGULATIONS).

SIGNATURE OF CLIENT: ________________________ DATE: _____________________

SIGNATURE OF GUARDIAN: _____________________ DATE: ______________________

SIGNATURE OF WITNESS: _____________________ DATE: _______________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

RELEASE OF INFORMATION OR AUTHORIZATION

I, __________________________________________________________________ _____ / _____ / ____
Consumer’s First Name Middle Initial Last Name Consumer’s Date of Birth
Authorize ___________________________________ to obtain information from, and share information with:
COUNSELING CENTER OF THE ROCKIES – NORTH 3489 W 72ND AVE STE 105 WESTMINSTER, C0 80030________
Name of Agency Address City, State, Zip
Unless unchecked, information may include:
 Assessment / Diagnosis / Family History  Medical Information / Medications Prescribed
 Treatment Summary and Recommendations  Drug / Alcohol History and Treatment
 Psychological Testing / Consultation  Service Plans
 Other: __Medical Emergencies____________________________________________________________________
Check only one box to indicate the purpose for which information is to be authorized/released:
 Treatment, Operations or Payment (If checked, this form becomes a Release and services can be refused in consumer
refuses to sign)
Specify: ______________________________________________________________________________________
 Other [e.g. Law (attorneys, probation), Education (schools) or Social Services] (If checked, this form becomes an
Authorization and under HIPAA rules, services may not be conditioned or refused if consumer refuses to sign.)
Specify: __Medical Emergencies____________________________________________________________________
• I understand that, unless lined-through, information can be released/authorized may include information regarding
the following condition(s):
• Drug Abuse • Psychiatric Conditions/Treatment
• Alcoholism or Alcohol Abuse • HIV / Auto Immune Deficiency Syndrome (AIDS)
• I understand that if this is a Release for “Treatment, Operations and Payment” purposes, CCRN may withhold
treatment or enrollment if I refuse to sign.
• I understand that if this is an Authorization for “Other” purposes, CCRN may not condition treatment or enrollment
whether I sign or not.
• If the information to released/authorized pertains to the diagnosis and treatment of alcoholism and drug abuse, I
understand that the confidentiality of the information is protected by Federal Law 42 C.F.R. Part 2.
• I understand that there is potential for information disclosed, as a result of this release/authorization, to be re-
disclosed by the recipient and therefore no longer protected by the HIPAA Privacy Regulation.
• I understand that I may revoke this release/authorization at any time by giving written notice to CCRN, except to the
extent that action has already been take to comply with it. Without such revocation, this release/authorization will
expire on _____ / _____ / _____ , or if left blank, one year from the date of my signature, or as of the action or event
of __Termination of Parole / Probation or Completion of Treatment if Self-Referred__________________________.
• I understand that I have a right to refuse to sign this form subject to the condition noted above or if I sign I am entitled
to a copy of the signed form.

__________________________________________ _____________________________________
Signature of Consumer / Parent / Legal Representative Relationship to Consumer
Date: ________________________ Witness: ___________________________________________
NOTICE TO WHOM THIS INFORMATION IS GIVEN: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal
Law prohibits you from making further disclosure of this information without the specific written consent of the person to whom it pertains.
A copy / facsimile of this Release / Authorization is as valid as the original.

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

RELEASE OF INFORMATION OR AUTHORIZATION

I, __________________________________________________________________ _____ / _____ / ____
Consumer’s First Name Middle Initial Last Name Consumer’s Date of Birth
Authorize ___________________________________ to obtain information from, and share information with:
COUNSELING CENTER OF THE ROCKIES – NORTH 3489 W 72ND AVE STE 105 WESTMINSTER, CO 80030
`Name of Agency Address City, State, Zip
Unless unchecked, information may include:
 Assessment / Diagnosis / Family History  Medical Information / Medications Prescribed
 Treatment Summary and Recommendations  Drug / Alcohol History and Treatment
 Psychological Testing / Consultation  Service Plans
 Other: ____________________________________________________________________________________
Check only one box to indicate the purpose for which information is to be authorized/released:
 Treatment, Operations or Payment (If checked, this form becomes a Release and services can be refused in consumer
refuses to sign)
Specify: ___ Treatment Records_ ______________________________________________________________
 Other [e.g. Law (attorneys, probation), Education (schools) or Social Services] (If checked, this form becomes an
Authorization and under HIPAA rules, services may not be conditioned or refused if consumer refuses to sign.)
Specify: ____________________________________________________________________________________
• I understand that, unless lined-through, information can be released/authorized may include information regarding
the following condition(s):
• Drug Abuse • Psychiatric Conditions/Treatment
• Alcoholism or Alcohol Abuse • HIV / Auto Immune Deficiency Syndrome (AIDS)
• I understand that if this is a Release for “Treatment, Operations and Payment” purposes, CCRN may withhold
treatment or enrollment if I refuse to sign.
• I understand that if this is an Authorization for “Other” purposes, CCRN may not condition treatment or enrollment
whether I sign or not.
• If the information to released/authorized pertains to the diagnosis and treatment of alcoholism and drug abuse, I
understand that the confidentiality of the information is protected by Federal Law 42 C.F.R. Part 2.
• I understand that there is potential for information disclosed, as a result of this release/authorization, to be re-
disclosed by the recipient and therefore no longer protected by the HIPAA Privacy Regulation.
• I understand that I may revoke this release/authorization at any time by giving written notice to CCRN, except to the
extent that action has already been take to comply with it. Without such revocation, this release/authorization will
expire on _____ / _____ / _____ , or if left blank, one year from the date of my signature, or as of the action or event
of __Termination of Parole / Probation___________________________________________________________.
• I understand that I have a right to refuse to sign this form subject to the condition noted above or if I sign I am entitled
to a copy of the signed form.

__________________________________________ _____________________________________
Signature of Consumer / Parent / Legal Representative Relationship to Consumer
Date: ________________________ Witness: ___________________________________________
NOTICE TO WHOM THIS INFORMATION IS GIVEN: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal
Law prohibits you from making further disclosure of this information without the specific written consent of the person to whom it pertains. A copy / facsimile of this
Release / Authorization is as valid as the original.

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

Patient Consent and Authorization Form for Disclosure of Substance Use Disorder Health
Information to Medicaid

Member (name and information of member whose health information is being disclosed):
Name:
ID# or DOB:
Substance Abuse Provider: Counseling Center of the Rockies (“Provider”)

Background: The behavioral health organizations (BHOs) listed below contract with the State of Colorado to
provide mental health and substance use services to Medicaid members. The BHOs in turn contract with
Provider to provide mental health and substance use services to Medicaid members. Medicaid has assigned you
to one of the BHOs for the management of your services. The BHOs process claims for services submitted by
Provider. The BHOs are also required to submit information on all claims paid or processed to Colorado
Medicaid for Medicaid administration purposes.
• I hereby authorize Provider to disclose my health information, including information related to my treatment
for alcohol and/or drug abuse, to one of the BHOs listed below to which I have been assigned for the purpose
of Provider submitting claims for payment to the BHO.
• I hereby further authorize the BHO listed below who has received and processed a claim for services delivered
to me by Provider, to re-disclose such information to Colorado Department of Health Care Policy and
Financing (Medicaid) for its Medicaid administration purposes as is required by the contract that the BHO
has with Medicaid.
BHOs Authorized to Receive and Re-Disclose Information:
Access Behavioral Care Behavioral Healthcare,
Inc.
Colorado Health Partnerships
Foothills Behavioral Health Partners, LLC
Beacon / Value Options
Northeast Behavioral Health Partnership

• My treatment may not be conditioned if I do not sign this form.

• I have received a copy of this signed document.
• I understand that I may revoke this authorization at any time by giving written notice to Provider, except to
the extent that the Provider or the BHO has already acted on it.
• This authorization will expire on the date that I am no longer a Colorado Medicaid member or two years from
the date of my signature, whichever is earlier.

Signature of Member or Legal Representative Date Signed

Print Name of Legal Representative (if applicable) Relationship to Client

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

ADMISSION DACOD
Admission Date: _____/______/_____ Provider Client Number: ____________________ Medicaid #: _______________________
Last Name: ________________________ First Name: ___________________ Middle Initial: ________
DOB: _____________ Zip Code: _______________ County: _____________________
Admission Modality:
Differential Assessment Number of prior detox episodes: ________
Traditional Outpatient Number of prior substance abuse treatment episodes______
Level I ED Gender: _______
Level II ED Pregnant: _______
Level II ED, TX Primary Race ______
Marital Status: Monthly Income: _______
Divorced # of persons living on income (including self) _________
Married # of children under the age of 18_______
Never Married Military Veteran? ___________
Separated Disabilities: ________
Widowed Highest School Grade Completed: ______ (GED=12, BA=16, etc)
Sexual Orientation: Employment Status:
Heterosexual Part Time (under 35 hrs per week)
Bisexual Full Time (35+ hrs per week)
Gay/Lesbian Disabled Homemaker
Other Unemployed Supported Employment
Declined Military Volunteer
Living Situation: Retired Student
Independent Living Halfway House Inmate
Correctional Facility Sober Living Has client ever experienced or witnessed a traumatic event?
Foster Home (Youth) Supported Housing Yes No
Group Home (Adult Assisted Living
Homeless
Primary Source of Income: ________
Health Insurance: Yes No Current Mental Health Problem? ________
Does insurance cover Substance Abuse Treatment? Yes No Medicaid #__________________
Referral Source: _____________________________ # of AA/NA/Self-Help Meetings attended last 30 days ________
Family Issues or Problems:
a. None (issues are temporary and relationships are generally positive)
b. Slight (some issues present, occasional friction or discord)
c. Moderate (frequent disruptions or turbulences in family functioning)
d. Severe (extensive disruptions of family functioning)
Socialization Issues or Problems:
a. None (able to form relationships with others)
b. Slight (difficulty developing or maintaining relationships)
c. Moderate (inadequate social skills resulting in tenuous and strained relations)
d. Severe (unable to form relationships)
Employment/ School Problems:
a. None (comfortable or competent in school or work)
b. Slight (occasional or mild disruption of performance in school or at work)
c. Moderate (occasional major or frequent minor disruption rarely meets expectations)
d. Severe (serious incapacity, absent motivation and ineffective functioning)
Medical/ Physical Problems:
a. None (no physical problems or well controlled chronic conditions)
b. Slight (occasional or mild problems that interfere with daily living)
c. Moderate (frequent or chronic health problems)
d. Severe (incapacitated due to medical/physical problems)
Drug use:
Primary ____________ Secondary___________ Tertiary___________
Use/ Abuse/ Dependent Use/ Abuse/ Dependent Use/ Abuse/ Dependent
# of times used last 30 days______ # of times used last 30 days______ # of times used last 30 days______
How used: ___________ How used: ___________ How used: ___________
Age 1st used_______ Age 1st used________ Age 1st used_______
Source of Drugs: _______ _______ _______
Last six months visited a medical or psychiatric emergency room: ______ Admitted: _________
Any DUI/DWAI Arrest in the past 30 days or any other arrest: _________Any other Arrest: _________
Out of State Offender: Yes No Tobacco Use: Smoker/tobacco user Former smoker/tobacco user Never smoker/tobacco user

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

MEDICAID ELIGIBILITY NOTICE

FOR CLIENTS WITH MEDICAID:

I UNDERSTAND THAT MY ELIGIBILITY FOR MEDICAID DOES NOT GUARANTEE MY TREATMENT WILL BE PAID
FOR. I ALSO UNDERSTAND THAT I MUST COMPLETE AN ASSESSMENT TO DETERMINE IF MY TREATMENT IS A
“MEDICAL NECESSITY”; I WILL BE INFORMED AS SOON AS POSSIBLE IF I DON’T QUALIFY FOR MEDICAID TO
COVER MY TREATMENT.

Client
Signature_________________________________________________________Date____________________________

Witness__________________________________________________________Date____________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

CONTRACT FOR TREATMENT

This is an agreement between Counseling Center of the Rockies and _________________________________________.

The staff of Counseling Center of the Rockies and the client agree to abide by the following policies:

____ Admission: No person shall be refused admission to the center on the basis of race, religion, gender, or physical
disability other than one which would prevent the client from receiving full benefit from the program. No client shall reject the
counseling or other client for the same reasons. No client may be refused admission solely on the basis of prior history of
relapse.

____ Attendance: I understand that I am allowed to miss the amount indicated below unless I am a DMV client. If I am a DMV
client I can be absent with the approval of staff only. If I exceed these absences, I may be in jeopardy of a non-cooperative
discharge.
If I am in a Level II program that is not DMV related, I am only allowed to be absent (excused or unexcused) for:
____ 2 classes for Level II Education
____ 2 classes for Track A&B Therapy
____ 3 classes for Track C Therapy
____ 4 classes for Track D Therapy
If you are doing any other therapy you shall have no more than _____ absences for the duration of your program.

_____ Confidentiality: What transpires between the Counseling Center of the Rockies and the client shall remain confidential
except in cases where the client has authorized the release of information, or is allowed in the case of a court order, an
emergency, for the purpose of a research audit or program evaluation, or for a child’s protection. A description of the federal
laws of confidentiality shall be provided to the client at admission and must be signed by the client. In instances where the
client breaches the confidentiality of another client who is seen in the counseling center, he/she may be discharged from the
program.

____ Dismissal: The client understands that he/she may be dismissed from the program for the following reasons: Being
excessively absent, failure to pay fees, disruptive behaviors, use of alcohol or other drugs, endangering another client’s life,
failure to submit to breath or drug testing, excessive positive breathalyzers or urine screens, failure to take Antabuse as
required, verbal or physical abuse, or breaching a client’s confidentiality.

____ Payment for services: Payment is always due at the time of service. The client shall abide by the signed consent for
financial responsibility included in this contract.

____ Grievance procedure: All problems or complaints shall first be taken up with whom the problem exists. In the even the
client has not received a satisfactory resolution with that person; the client may contact the Clinical or Administrative Director.
The Director(s) shall provide a full and open hearing on the matter and will do whatever is feasible to resolve the problem.

____ Client’s responsibilities: The client shall be expected to keep all scheduled appointments, group sessions and
Antabuse/drug testing appointments. Missed group appointments will have to be made up at a later date. Make-up classes
are offered once or twice a month. Missed drug testing may only be made up with PO’s permission. The client shall be
expected to report any change in address or telephone numbers to the probation office/case manager as well as CCR staff.

____ The client understands he/she is to make arrangements for daycare during scheduled appointments. Children shall not
attend group or individual sessions, except in the case of family therapy. Children under the age of twelve shall not be left
unattended in the facility.

____ Several times per year the agency closes due to a holiday, severe weather, or staff training functions. The agency will
reschedule all services in order to provide continuous services to the client. The client shall plan to attend the rescheduled
make up days.

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

____ From time to time the counseling staff will recommend the client attend a support group or other resource meeting. It is
recommended that the client pursue these programs and it may be written in their discharge summary if the recommendation
was not followed.

____ Physical violence such as pushing, shoving, hitting, or any other form of aggressive touch will not be tolerated. If the
client is involved in such behavior, the police shall be contacted and the client shall be terminated from the program. Verbal
abuse such as profanity used abusively or threats made will not be tolerated. Clients involved in verbal abuse will be asked to
leave the premises and shall have additional sessions with their counselor to determine continued status in the program.

____ What is said in group stays in group. All clients and staff members shall observe the strictest confidentiality so all clients
can feel safe in group. Please do not repeat outside of group what another member has shared.

____ I understand that I am required to abstain from the use of alcohol and illicit drugs while I am enrolled in counseling at
Counseling Center of the Rockies.

____ Orientation: I have received written or verbal information regarding my assigned counselor, fire alarms, group locations
and times, and I have received, read, and understood the Contract for treatment and my rights and responsibilities as a client.

CONSENT FOR TREATMENT

I consent to such evaluation and treatment as the professional staff at the Counseling Center of the Rockies may decide. I
am aware that care and treatment in this area is not an exact science and that no guarantees have been made as to the result
of my evaluation and treatment at the counseling center.

I certify that I have read and fully understand the contents of the above statement.

Client: ______________________________________________ DATE: _______________________

Witness: ____________________________________________ DATE: ________________________

Consent to Financial Responsibility

I agree to pay for services at the time of service unless written arrangements are made. I understand that payment for drug
tests is due at the time of service and payment for breathalyzers is due by the 10th of each month. I understand that my
account is to be current at all times in order to attend.
I have received a copy of the fee schedule and I understand my estimated cost of treatment will be:

Evaluation_______, Intake________, Groups________for_______weeks, Books_____,

Individual Sessions_______for______weeks, Drug Testing______(avg.#)________,

Monitoring Fees________ for_____months.

My estimated total cost of treatment is ________________. Any prepayment is non-refundable.

Drug testing will be done by NORCHEM.

CLIENT: ______________________________________________ DATE: __________________________

WITNESS: ____________________________________________ DATE: __________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

RECEIPT OF HIPPA NOTICE OF PRIVACY

PRACTICES
In signing this form, you agree that you have received our Notice of Privacy Practices. This Notice, among
other points, explains how we plan to use and disclose your protected health information for the purposes of
treatment, payment and health care operations. This applies to the privacy practices of Counseling Center of
the Rockies.
You have the right to review our Notice of Privacy Practices prior to signing this form. It provides more detail
on how we may use and disclose your information. The Notice of Privacy Practices may change. A current
copy may be requested by contacting our Privacy Officer, Jamie Bacon at 303-806-0933.
By signing this form, you acknowledge you have received our Notice of Privacy Practices and that Counseling
Center of the Rockies can use and disclose your protected health information in accordance with HIPAA.

Signature of individual or surrogate decision maker

______________________________ ______________________________ ____________

FULL NAME SIGNATURE DATE

Relationship to resident/patient/legal authority (if applicable)

______________________________ ______________________________ ____________

FULL NAME SIGNATURE DATE

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

Interstate Compact Unit

940 N Broadway
Denver, CO 80203
P 303.763.2441 F 303.861.1548
[email protected] | DOC_interstatetreatment.state.co.us

OUT-OF-STATE OFFENDER
CLIENT QUESTIONNAIRE

The following questions must be answered by all clients seeking admission to this program for any education or
treatment; as required by Colorado law. Refusal to cooperate, or failure to provide complete or accurate
information, including failure to sign a release of information to the referring criminal justice agency, will result
in a denial to attend the treatment program and notification of authorities, in accord with the requirements in
C.R.S. 17-27.1-101.

1) Are you required to report your treatment progress or completion to any Court,
Department of Corrections, Parole, Probation, Adult Diversion Program, or DMV? _____Yes _____No

2) Do you have any pending cases in another state? _____Yes _____No

If yes to 1 or 2, please answer the following questions:

3) What state are you completing treatment for?

4) Who are you to report the treatment to?

(Example: Court, Judge, Probation Parole, etc.)

5) Are you, or will you be under the supervision of a Probation or Parole Officer in
Colorado? _____Yes ______No

6) For DUI Offenders only: Are you seeking education or treatment for the sole purpose of restoring you driving
privileges as the result of an alcohol or drug related driving
Offense in another state, but are not under court order to do so? ______Yes ______No

Your Name: Date of Birth:

Social Security Number: Place of Birth:

Signature: Today’s Date:

If you answered “Yes” to 1 or 2 above, please provide the following:

Name, address and phone number of your

Probation officer, parole officer, judge
Or diversion officer.

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

CLIENT PERSONAL EVALUATION

Group ID#__________________________________ Client #__________________________________

1.) I feel I have had a drinking/drug problem in the past____________________________________

_____________________________________________________________________
_____________________________________________________________________

2.) I feel I may now have a drinking/drug problem________________________________________

_____________________________________________________________________
_____________________________________________________________________
3.) How do you feel about being in group sessions? _______________________________________
_____________________________________________________________________
_____________________________________________________________________
4.) What do you hope to gain from group sessions? _______________________________________
_____________________________________________________________________
_____________________________________________________________________
5.) Problems that exist in my life today_________________________________________________
_____________________________________________________________________
_____________________________________________________________________

6.) What do you think about current laws that you are currently sentenced under? _______________
_____________________________________________________________________
_____________________________________________________________________
7.) Other comments________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Clients Signature __________________________________ Date: ___________________________

Staff Signature ____________________________________ Date: ___________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

APPOINTMENT REMINDERS

Can we text and/or email you appointment reminders?

Text: _____Yes _____No

If yes: Cell phone number ____________________________
Cell phone Carrier: _____________________________________
(ie: Alltel, ATT, Boost Mobile, Cricket Wireless, Lyca Mobile, Project Fi,
Simple Mobile, Sprint, Straight Talk, TextNow, T-Mobile, TracFone, US
Cellular, Verizon, Virgin Mobile, Xfinity)

Email _____Yes _____No

If yes: Email address:__________________________________________

Client signature:____________________________________________

Name: ____________________________________________________
(Please print)

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

INFECTIOUS DISEASE BEHAVIORAL SCREEN

Name________________________________________________________ Date __________________________________
For clinical use only
I understand that my responses to this Screen are protected under the federal regulations At risk for HIV
governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and If so is at:
cannot be disclosed without my written consent unless otherwise provided for in the Medium risk
regulations. I also understand that HIV, STD and TB related information about me is High risk
Score: ___________
protected by state law and cannot be disclosed unless state law authorizes the disclosure. (ADAD ID Screening
Instruments Rev. 8/02)
 I have read and understand the above. Signature: __________________

Please mark the one most accurate response to each question.

1. Have you had 2 or more sexual partners in the past 10 years?

 Yes No

2. Have you had anal sex (penis in anus) with any of your sexual partners during the past 10 years?

 Yes No

3. How often have you used a condom when having anal sex in the past 10 years?

 Never Sometimes Always Have not had anal sex

4. Have you ever had a sexually transmitted disease such as gonorrhea, syphilis, Chlamydia, genital warts (HPV) genital
herpes, or hepatitis?

 Yes No

5. At any time in the past 10 years, have you ever given money or drugs to anyone to have sex with you?

 Yes No

6. Have you ever had sex with someone so that they would give you money or drugs?

 Yes No

7. Have you ever injected street drugs, steroids, or vitamins with a needle?

 Yes No

8. Have any of your sexual partners in the past 10 years ever injected street drugs, steroids, or vitamins with a needle?

 Yes No Don’t Know

9. Have any of your sexual partners in the past 10 years been men who have had sex with other men?

 Yes No Don’t Know

10. Have any of your sexual partners in the past 10 years ever had a sexually transmitted disease such as gonorrhea, syphilis,
Chlamydia, genital warts (HPV) genital herpes, or hepatitis?

 Yes No Don’t Know

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

INFECTIOUS DISEASE MEDICAL SCREEN

Name__________________________________________ Date _____________________________

I understand that my responses to this screen are protected under the federal regulations governing Confidentiality of
Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without written consent unless
otherwise provided for in the regulation. I also understand that HIV, STD and TB related information about me is
protected by state law and cannot be disclosed unless state law authorizes the disclosure.

 I have read and understand the above. Signature: ___________________________________

For clinician use only:

____At risk for TB
(Based on positive response to any question 9-14)
Please mark the one most accurate response to each question. (ADAD ID Screening Instruments Rev. 8/02)

1. Have you been a recipient of a blood transfusion or organ transplant prior to 1992 (including receiving blood during
birth or other surgical procedures)?

 Yes No

2. Have you ever been or are you now on long-term hemodialysis (blood cleansing)?

 Yes No

3. Are you a recipient of clotting factor made prior to 1987?

 Yes No

4. Have you ever been stuck by a needle or anything sharp that was likely to have been contaminated with hepatitis C-
infected blood?

 Yes No

5. Were you born to a mother who had hepatitis?

 Yes No

6. Have you ever had symptoms of liver disease or abnormal liver function/enzyme test?

 Yes No

7. Have any of your sexual partners been infected with hepatitis B or C?

 Yes No
8. Have you been the recipient of tattooing to body piercing in unsanitary conditions (e.g. unsterile needles)?

 Yes No
9. Mark all of the following that currently apply to you or that applied to you in the past.
 Close contact with active TB
 Medical Condition that increases risk of TB disease (e.g. HIV, other immune disorders, diabetes)
 Abnormal chest X-ray showing fibrotic lesions

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

INFECTIOUS DISEASE MEDICAL SCREEN -CONT’D

 Resident or employee of a high-risk group setting (e.g. correctional facilities, nursing homes, mental institution,
homeless shelter, residential treatment, etc.)
 Health care worker or volunteer who serves high-risk clients
 Foreign-born person who has arrived within the last five years from countries that have a high TB incidence or
prevalence (e.g. most countries in Africa, Asia, Latin America, Eastern Europe, and Russia.)
 Person from a medically underserved, low-income population
 Member of a high-risk racial, ethnic, or other minority population with an increased prevalence of TB (e.g. Asian
and Pacific Islanders, Hispanics, African-American, Native Americans, migrant farm workers, homeless persons).
 History of inadequately treated TB

10. Have you had a cough for more than three weeks?

 Yes No

11. Have you coughed up blood/colored mucous?

 Yes No

12. Do you have swollen, non-tender lymph nodes?

 Yes No

13. Have you had a prolonged loss of appetite or unexplained weight loss of ten pounds or more?

 Yes No

14. Have you had recurrent fevers or heavy night sweats for more than three weeks?

 Yes No

Response Guide:

If you answered “yes” to any question # 1-7, please see your counselor for a referral to be screened for hepatitis B and C.

If you answered “yes” to question #8, please see your counselor for a referral for infected disease screening and testing.

If you answered “yes” to any of the categories in question #9, please see your counselor for a referral to be screened and
for tuberculosis.

If you answered “yes” to any question #10-14, please see your counselor immediately for a referral for tuberculosis
screening and treatment.

Your counselor is referring you to the following program/agency for follow-up:

Program/Agency:_______________________________________________________________
Address:______________________________________________________________________
Contact:_______________________________________________________________________
Phone:________________________________________________________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

INFECTIOUS DISEASE BEHAVIORAL SCREEN SCORING

INFECTIOUS DISEASE BEHAVIORAL SCREEN SCORING

Client/Patient Name/ID: _________________________________________ Date: ________________

Transfer responses from the Infectious Disease Behavioral Screen onto this form and total the corresponding
numeric values.

1. Yes (5) No (0)

2. Yes (10) No (0)

3. Never (20) Sometimes (15) Always (10) No anal sex (0)

4. Yes (15) No (0)

5. Yes (10) No (0)

6. Yes (20) No (0)

7. Yes (30) No (0)

8. Yes (30) No (0) Don’t know (15)

9. Yes (30) No (0) Don’t know (15) 10. Yes (30) No (0) Don’t know (15)

My score: _______________________________________________________________________

Scoring Guide:

□ 0 to 29 indicates low risk for acquiring/transmitting HIV. You do not need to be evaluated further, unless it is believed
to be necessary based on other infom1ation you have provided.

□ 30 to 119 indicates medium risk for acquiring/transmitting HIV and hepatitis. You should receive further evaluation
and appropriate referrals should be provided.

□ 120 or higher indicates high risk for acquiring/transmitting HIV and hepatitis. You should contact the Colorado
Department of Public Health and Environment, 303-692-2759, or your local county health department for further
evaluation and follow-up.

Note: Answering "yes" to question 7 indicates past or present injection drug use and testing for HIV and hepatitis B and
C is strongly encouraged as behaviors associated with injection drug use place you at an increased risk for acquiring
and/or transmitting these infections.

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

BIOPSYCHOSOCIAL ASSESSMENT
Client Name _______________________________ Date ________________Client ID#_____________

The following information is for our records and will be used for assessment and to help staff develop
treatment plans for you. Please answer all areas that apply leaving blank those areas that do not apply.
When you get to the areas of drugs and alcohol use-this includes ANY use-including experimental uses
in the past along with your current substance use.

PERSONAL INFORMATION:

Date & Place of Birth_____________________________________________________________

Ethnic Background_____________________________ Cultural Identification _______________

(Anglo, Black, Hispanic, White, etc.) (American, Irish, Spanish, etc.)

Sexual Orientation: Heterosexual Homosexual Bisexual

What do you consider your personal strengths? _____________________________________________

What do you consider your personal weaknesses? ___________________________________________

How do you use leisure time? ___________________________________________________________

________________________________________________________________________
Do you have any social problems? Yes  No, if Yes explain: ________________________________
________________________________________________________________________
Who do you socialize with and what do you do when you socialize? _____________________________
________________________________________________________________________

Do you have a profession, trade or skill? Yes  No, if Yes specify: ___________________________

Does anyone contribute to the majority of your financial support? Yes  No If Yes, who? _________

What has been your usual employment pattern for the last 3 years? ______________________________
(Part time, Full time, Student, Retired, Unemployed, etc.)

How many days out of the last 30 days have you experienced employment problems? _______________

Usual living arrangements for the past three years? __________________________________________

Do you live with anyone who has a current alcohol problem?  Yes  No If yes, please specify:
____________________________________________________________________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

BIOPSYCHOSOCIAL ASSESSMENT – CONT’D

Do you live with anyone who used non-prescribed drugs?  Yes  No If yes, please specify:
____________________________________________________________________________________

With whom do you spend most of your free time? ___________________________________________

Where do you see yourself in?

1yr_________________________________________________________________________________
3yrs________________________________________________________________________________
5yrs________________________________________________________________________________

MEDICAL STATUS:
Have you had a physical health exam in the last year? Yes  No. If no, do you have a Primary Care
Physician? Yes  No. If no, please see staff for help in finding a Primary Care Physician.

How many times in your life have you been hospitalized overnight for medical problems? ___________

For what reason(s) were you hospitalized? _________________________________________________

Do you have any chronic medical problems that interfere with your daily life? Yes  No If yes,
please specify________________________________________________________________________

Are you taking any prescribed medication on a regular basis for a physical problem? Yes  No If yes,
please specify________________________________________________________________________

Do you receive a pension for a physical disability? Yes  No If yes, please specify: ______________

Do you have any developmental or functional disabilities (including TBI, problems related to aging,
learning disabilities, etc.)? Yes  No If yes, please specify: _________________________________
_______________________________________________________________
Dental Health Status: Excellent  Very Good  Good  Fair  Poor

How many days out of the last 30 days have you experienced medical problems? __________________
CRIMINAL HISTORY:
Charges:
Year Description of Charge Incarcerated/Length
_____ _________________________________________________________ __________________

_____ _________________________________________________________ __________________

_____ _________________________________________________________ __________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

BIOPSYCHOSOCIAL ASSESSMENT – CONT’D

FAMILY RELATIONSHIP HISTORY:

Are you currently:  Married  Divorced  Never Married  Widowed  Separated  Remarried
How long have you been in your current marital status? ______________________________________
Do you have children? YesNo. If yes, what genders/ages? _________________________________

What are their living arrangements? ______________________________________________________

Was your family of origin or adoptive family (check one)  Distant (anger& fighting)  Not close (went
their separate ways)  Very close (spent time together)  Other(explain)________________________
What was expected of you? _____________________________________________________________

Were your parents separated or divorced Yes  No If yes. Who did you live with?_______________
How were you affected?________________________________________________________________

Did either parent remarry Yes  No  Dad ______times,  Mom ______times.

How many brothers___ sisters___ do you have? Are you the oldest/middle/youngest____________?

How old were you when you left home? ______. For what reason did you leave home? ____________
________________________________________________________________________

Is either parent deceased? Yes  No. If yes, how old were you when they died? ________years old
when mother died ______years old when father died.

Other Family Dynamics:

Medical Problems in the family YesNo

Substance Abuse Problems in the family YesNo
Mental Illness in the family YesNo
Suicide in the family YesNo
Death in the immediate family YesNo
Family member physically or sexually abused someone YesNo
You yourself physically or sexually abused by a family member YesNo
You yourself physically or sexually abused by another person YesNo
You physically or sexually abusing a family member or person YesNo
If you have answered yes to any of the above, please note a brief explanation of the situation and how
you have been affected.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

____________________________________________________________________________________
____________________________________________________________________________________
BIOPSYCHOSOCIAL ASSESSMENT – CONT’D
PSYCHIATRIC STATUS:
Have you ever been treated for psychological or emotional problems in a hospital or inpatient setting?
 Yes  No If yes, please specify: ______________________________________________________

Have you ever been treated for psychological or emotional problems as an outpatient/private patient?
 Yes  No If yes, please specify: ______________________________________________________

Do you receive a pension for a psychiatric disability?  Yes  No If yes, please specify: __________
____________________________________________________________________________________

Have you had a significant period of time (that was not a direct result of alcohol/drug use) in which
you have experienced any of the following to the point you have been unable to function:
Serious depression, hopelessness  Yes  No
Serious anxiety, unreasonable worried  Yes  No
Hallucinations?  Yes  No
Trouble understanding or remembering?  Yes  No
If you answered yes to any of the above, please specify if any in the last 30 days and if you have
received or would like to receive treatment for the problem: ___________________________________
________________________________________________________________________
________________________________________________________________________
Have you had a significant period of time in which you have:
Experienced trouble controlling violent behavior?  Yes  No If yes, when? ____________________
____________________________________________________________________________________
Experienced serious thoughts of suicide or attempted suicide?  Yes  No If yes, when? ___________
____________________________________________________________________________________

Have you been prescribed medication for a psychological or emotional problem?  Yes  No If yes,
when and what medication(s)? ___________________________________________________________

How many days out of the last 30 days have experienced psychological or emotional problems? ______
SUBSTANCE USE HISTORY:
1ST DRUG OF CHOICE:  Alcohol  Marijuana  Heroin  Other Opiates __________________
 Cocaine  Crack  Methamphetamines  Other Amphetamines __________________________
 Inhalants  Sedatives/Tranquilizers (Sleeping pills, Valium, Xanax, Klonopin, etc)

How old were you when you began using your 1st drug of choice? __________________

How much and how often would you use your 1st drug of choice? _______________________________

Give the situation(s) where you would use your 1st drug of choice? ____________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

BIOPSYCHOSOCIAL ASSESSMENT – CONT’D

In the past 30 days how many times have you used your 1st drug of choice? ______________________

When was the date of your last use of your 1st drug of choice? _________________________________

Is your 1st drug of choice a problem for you now?  Yes  No If yes, please explain_______________
____________________________________________________________________________________

Have you had prior education, therapy, detoxification due to use of your 1st drug of choice? _______If
yes, where and when? ________________________________________________________________

Have you had prior legal problems related to your 1st drug of choice?  Yes  No If yes, when and
what were your charges? ______________________________________________________________

Have you had any withdrawal symptoms from your 1st drug of choice in the past 30 days?  Yes  No
If yes, when and what were the symptoms? ________________________________________________
____________________________________________________________________________________

Have you had any cravings for your 1st drug of choice in the past 30 days?  Yes  No If yes, how
often? _____________________________________________________________________________

2ND DRUG OF CHOICE:  Alcohol  Marijuana  Heroin  Other Opiates _________________

 Cocaine  Crack  Methamphetamines  Other Amphetamines __________________________
 Inhalants  Sedatives/Tranquilizers (Sleeping pills, Valium, Xanax, Klonopin, etc)

How old were you when you began using your 2nd drug of choice? __________________

How much and how often would you use your 2nd drug of choice? _____________________________

Give the situation(s) where you would use your 2nd drug of choice? ____________________________

In the past 30 days how many times have you used your 2nd drug of choice? ____________________

When was the date of your last use of your 2nd drug of choice? _______________________________

Is your 2nd drug of choice a problem for you now?  Yes  No If yes, please explain:
____________________________________________________________________________________

Have you had prior education, therapy, detoxification due to use of your 2nd drug of choice? _______If
yes, where and when? ________________________________________________________________
Have you had prior legal problems related to your 2nd drug of choice?  Yes  No If yes, when and
what were your charges? ______________________________________________________________
Have you had any withdrawal symptoms from your 2nd drug of choice in the past 30 days?  Yes 
No If yes, when and what were the symptoms? ______________________________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

BIOPSYCHOSOCIAL ASSESSMENT – CONT’D

Have you had any cravings for your 2nd drug of choice in the past 30 days?  Yes  No If yes, how
often? _____________________________________________________________________________

3RD DRUG OF CHOICE:  Alcohol  Marijuana  Heroin  Other Opiates _________________

 Cocaine  Crack  Methamphetamines  Other Amphetamines __________________________
 Inhalants  Sedatives/Tranquilizers (Sleeping pills, Valium, Xanax, Klonopin, etc)

How old were you when you began using your 3rd drug of choice? __________________

How much and how often would you use your 3rd drug of choice? _____________________________

Give the situation(s) where you would use your 3rd drug of choice? ____________________________

In the past 30 days how many times have you used your 3rd drug of choice? ____________________

When was the date of your last use of your 3rd drug of choice? _______________________________

Is your 3rd drug of choice a problem for you now?  Yes  No If yes, please explain:
____________________________________________________________________________________

Have you had prior education, therapy, detoxification due to use of your 3rd drug of choice? _______If
yes, where and when? ________________________________________________________________
Have you had prior legal problems related to your 3rd drug of choice?  Yes  No If yes, when and
what were your charges? ______________________________________________________________
Have you had any withdrawal symptoms from your 3rd drug of choice in the past 30 days?  Yes 
No If yes, when and what were the symptoms? ______________________________________________
____________________________________________________________________________________
Have you had any cravings for your 3rd drug of choice in the past 30 days?  Yes  No If yes, how
often? _____________________________________________________________________________

FREQUENCY:
In regards to your alcohol and drug use, past or present, please answer the following:

1) Do you or did you use alcohol/drugs throughout the day?

None Sometimes Often All the time

2) Do you or did you carry alcohol/drugs with you?

None Sometimes Often All the time

3) Describe your use of alcohol/drugs in the past 3 months

None Sometimes Often All the time

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

BIOPSYCHOSOCIAL ASSESSMENT – CONT’D

4) Which of the following reasons best describe why you use alcohol/drugs?
To Socialize To Celebrate Occasions To get High
To Relax  To Escape Problems To Get Drunk
To Forget To Stop Shaking To fall Asleep
To reduce pain For Unknown Reasons
Other _______________________________________________________________________

Client Signature__________________________ Reviewed by: ______________________________

(Clinician Signature)
Date___________________________________ Date____________________________________

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

YOUR MASTER PROFILE (MP)

I. ALCOHOL AND OTHER DRUG USE ASSESSMENT
LEVEL OF INVOLVEMENT IN DRUG
USE
YOUR QUANTITY/FREQUENCY OF USE NONE OR LOW MODERATE HIGH
Alcohol Involvement 1 1 2 3 4 5 6 7 8 9 10
Marijuana Involvement 1 1 2 3 4 5 6 7 8 9 10
Cocaine Involvement 1 1 2 3 4 5 6 7 8 9 10
Amphetamine Involvement 1 1 2 3 4 5 6 7 8 9 10
Other Drugs 1 1 2 3 4 5 6 7 8 9 10

STYLE OF ALCOHOL/OTHER DRUG USE NONE OR LOW MODERATE HIGH

Convivial or Gregarious Use 1 1 2 3 4 5 6 7 8 9 10
Solo or Use by Yourself 1 1 2 3 4 5 6 7 8 9 10
Sustained or Continuous Use 1 1 2 3 4 5 6 7 8 9 10

BENEFITS OF AOD USE TO… NONE OR LOW MODERATE HIGH

Cope with Social Discomfort 1 1 2 3 4 5 6 7 8 9 10
Cope with Emotional Discomfort 1 1 2 3 4 5 6 7 8 9 10
Cope with Relationships 1 1 2 3 4 5 6 7 8 9 10
Cope with Physical Distress 1 1 2 3 4 5 6 7 8 9 10

NEGATIVE CONSEQUENCES OF USE NONE OR LOW MODERATE HIGH

Behavioral Disruption from Use 1 1 2 3 4 5 6 7 8 9 10
Emotional Disruption from Use 1 1 2 3 4 5 6 7 8 9 10
Physical Disruption from Use 1 1 2 3 4 5 6 7 8 9 10
Social Irresponsibility from Use 1 1 2 3 4 5 6 7 8 9 10
Overall Negative Consequences 1 1 2 3 4 5 6 7 8 9 10

CATEGORIES OF AOD USE PROBLEMS NONE OR LOW MODERATE HIGH

Drinking/Drug Use Problem 1 1 2 3 4 5 6 7 8 9 10
Problem Drinker or Drug Use 1 1 2 3 4 5 6 7 8 9 10
Alcohol/Other Drug Abuse 1 1 2 3 4 5 6 7 8 9 10
Alcohol/Other Drug Dependent 1 1 2 3 4 5 6 7 8 9 10

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

YOUR MASTER PROFILE (MP)

II. IMPAIRED DRIVING ASSESSMENT
LEVEL OF PROBLEM SEVERITY
AREAS OF IMPAIRED DRIVING
PROBLEMS AND RISK NONE OR LOW MODERATE HIGH
BAC Level at Time of Arrest 1 1 2 3 4 5 6 7 8 9 10
Disruption to your Lifestyle 1 1 2 3 4 5 6 7 8 9 10
Bodily Injury to Yourself 1 1 2 3 4 5 6 7 8 9 10
Bodily Injury to Others 1 1 2 3 4 5 6 7 8 9 10
Property Damage Including Car 1 1 2 3 4 5 6 7 8 9 10
Overall Problems from DWI 1 1 2 3 4 5 6 7 8 9 10
Overall Driving Risk 1 1 2 3 4 5 6 7 8 9 10

III. ASSESSMENT OF THINKING, FEELING & ATTITUDE PATTERNS

LEVEL OF PROBLEM SEVERITY
THINKING, FEELING AND ATTITUDE
PATTERNS THAT LEAD TO NEGATIVE
BEHAVIOR / CONDUCT NONE OR LOW MODERATE HIGH
Blame Others for Problems 1 1 2 3 4 5 6 7 8 9 10
Victim Stance 1 1 2 3 4 5 6 7 8 9 10
Careless: Don’t Care 1 1 2 3 4 5 6 7 8 9 10
Think You Are Better Than Others 1 1 2 3 4 5 6 7 8 9 10
Irresponsible Thinking 1 1 2 3 4 5 6 7 8 9 10
Act Without Thinking 1 1 2 3 4 5 6 7 8 9 10
Angry and Aggressive Thinking 1 1 2 3 4 5 6 7 8 9 10
Feeling Depressed and Sad 1 1 2 3 4 5 6 7 8 9 10
Rebellious Against Authority 1 1 2 3 4 5 6 7 8 9 10
Time with Drinking Friends 1 1 2 3 4 5 6 7 8 9 10
Friends Angry at Laws and Society 1 1 2 3 4 5 6 7 8 9 10
Conflict with Spouse/Family 1 1 2 3 4 5 6 7 8 9 10
Second Home at Bar 1 1 2 3 4 5 6 7 8 9 10
Having Bad/Unpleasant Feelings 1 1 2 3 4 5 6 7 8 9 10
Loss of Self-Importance 1 1 2 3 4 5 6 7 8 9 10
Loss of Someone Important 1 1 2 3 4 5 6 7 8 9 10

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

YOUR MASTER PROFILE (MP)

IV. BACKGROUND: PROBLEMS OF CHILDHOOD AND DEVELOPMENT

LEVEL OF PROBLEM SEVERITY
PROBLEMS IN CHILDHOOD AND TEENAGE
YEARS NONE OR LOW MODERATE HIGH
Teenage Alcohol/Drug Use 1 1 2 3 4 5 6 7 8 9 10
Problems with Law During Teens 1 1 2 3 4 5 6 7 8 9 10
Problems with Parents/Family 1 1 2 3 4 5 6 7 8 9 10
Emotional-Psychological 1 1 2 3 4 5 6 7 8 9 10
School Adjustment Problems 1 1 2 3 4 5 6 7 8 9 10
Physical Illness in Childhood 1 1 2 3 4 5 6 7 8 9 10

V. CURRENT LIFE SITUATION PROBLEMS

LEVEL OF PROBLEM SEVERITY
AREAS OF ADULT PROBLEMS NONE OR LOW MODERATE HIGH
Job and Employment Problems 1 1 2 3 4 5 6 7 8 9 10
Financial and Money Problems 1 1 2 3 4 5 6 7 8 9 10
Unstable Living Situation 1 1 2 3 4 5 6 7 8 9 10
Social-Relationship Problems 1 1 2 3 4 5 6 7 8 9 10
Marital-Family Problems 1 1 2 3 4 5 6 7 8 9 10
Emotional-Psychological 1 1 2 3 4 5 6 7 8 9 10
Problems with the Law 1 1 2 3 4 5 6 7 8 9 10
Physical Health Problems 1 1 2 3 4 5 6 7 8 9 10

VI. MOTIVATION AND READINESS FOR TREATMENT

LEVEL OF PROBLEM SEVERITY
AREAS OF ASSESSMENT NONE OR LOW MODERATE HIGH
Awareness of Alcohol or Drug Problem 1 1 2 3 4 5 6 7 8 9 10
Awareness of Legal Problem 1 1 2 3 4 5 6 7 8 9 10
Acknowledge Need for Help 1 1 2 3 4 5 6 7 8 9 10
Willingness to Accept Help 1 1 2 3 4 5 6 7 8 9 10
Willingness to Participate in Treatment 1 1 2 3 4 5 6 7 8 9 10
Have Taken Action to Change 1 1 2 3 4 5 6 7 8 9 10

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 Informed Consent for Telehealth Services

CLIENT NAME: _____________________________ DATE OF BIRTH: M EDICAL RECORD #:

LOCATION OF CLIENT: ________________________ ______________ ________________

DATE CONSENT
Counseling Center of the Rockies
COUNSELOR/THERAPIST: ____________________________________________ DISCUSSED:
3489 W 72nd Ave, Suite 105, Westminster, CO 80030
LOCATION: _________________________________ ____________

Introduction
Online psychotherapy, also known as telemental health services ("telehealth"), involves a
therapist or counselor providing psychological counseling and support over the Internet through
email, video conferencing, online chat, or phone calls. The information may be used for
diagnosis, therapy, follow-up and/or education.

Electronic systems used will incorporate network and software security protocols to protect the
confidentiality of client identification and imaging data, and will include measures to safeguard
the data to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
• Improved access to mental health services by enabling the client to remain in his/her home or
other remote site.
• Mental health services are more accessible and convenient—increasing mental health
treatment outcomes.
• More efficient evaluation and continuity of mental health services.

Possible Risks:
There are potential risks associated with the use of telehealth services. These risks include, but
may not be limited to:
• In rare cases, information transmitted may not be sufficient to allow for appropriate decision
making by the counselor/therapist;
• Delays in evaluation and treatment could occur due to deficiencies or failures of the
equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal
information;

Please initial after reading this page: __________

Copyright 2020 Between Sessions Resources

Informed Consent for Telemental Health Services Page 2

By signing this form, I understand the following:

1. I understand the laws that protect privacy and the confidentiality of information also apply to
telehealth services, and no information obtained in the use of this service which identifies me
will be disclosed to researchers or other entities without my consent.
2. I understand I have the right to withhold or withdraw my consent to the use of telehealth in
the course of my care at any time, without affecting my right to future care or treatment.
3. I understand I have the right to inspect all information obtained and recorded in the course of a
telehealth session, and I may receive copies of this information.
4. I understand that a variety of alternative methods of therapeutic care may be available to me,
and that I may choose one or more of these at any time. My counselor/therapist has explained
the alternatives to my satisfaction.
5. I understand telehealth services may involve electronic communication of my personal
information.
6. I understand I may expect benefits from the use of telehealth services, but that no results can
be guaranteed or assured.

Patient Consent To The Use of Telehealth Services

I have read and understand the information provided above regarding telehealth. I have
discussed it with my counselor/therapist, and all of my questions have been answered to my
satisfaction. I hereby give my informed consent for the use of telehealth in my
psychotherapeutic care.
Counseling Center of the Rockies
I hereby authorize _______________________________ (name of counselor/therapist) to
use telehealth in the course of my diagnosis, evaluation, and treatment.

Signature of Client (or person

authorized to sign for patient): Date:

If authorized signer,
relationship to client:

Witness: Date:

I have been offered a copy of this consent form (client initials) _______

Copyright 2020 Between Sessions Resources

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax: 720-612-4239 Fax: 303-806-0935

Service Plan

Name: _____________________________________ Date: __________

What are your strengths?

__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

What are your weaknesses?

__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax: 720-612-4239 Fax: 303-806-0935

Service Plan Draft

NAME: ________________________________________ DATE: _____________

PROBLEM #1: _______________________________________________________

___________________________________________________________________
___________________________________________________________________
GOAL #1: ___________________________________________________________
___________________________________________________________________
___________________________________________________________________
PLAN #1: ___________________________________________________________
___________________________________________________________________
___________________________________________________________________

PROBLEM #2: _______________________________________________________

___________________________________________________________________
___________________________________________________________________
GOAL #2: ___________________________________________________________
___________________________________________________________________
___________________________________________________________________
PLAN #2: ___________________________________________________________
___________________________________________________________________
___________________________________________________________________
 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax: 720-612-4239 Fax: 303-806-0935

PROBLEM #3: _______________________________________________________

___________________________________________________________________
___________________________________________________________________
GOAL #3: ___________________________________________________________
___________________________________________________________________
___________________________________________________________________
PLAN #3: ___________________________________________________________
___________________________________________________________________
___________________________________________________________________

By signing this form, I agree with the above service plan.

Client Signature: ____________________________________ Date: __________

Therapist Signature: __________________________________ Date: __________

Example of Service Plan:

What are your personal strengths: (list at least a few)

What are areas that you need to work on or improve: (list at least a few)

Goal #1:
Problem: what is a problem or area in your life that needs attention?
Goal: what do you want this area to look or be like in the future?
Plans: what are specific things that you are doing or need to do to
help achieve your goal?

Goal #2:
Problem: what is another problem or area that needs attention?
Goal: what do you want this 2nd area to be like?
Plans: specific things you are doing or need to do to achieve 2nd
goal?

Here are examples of goals:

Problem: I realize I have a drinking problem and drinking keeps causing problems in my
life
Goal: stay sober while on probation and stay sober long-term
Plans: 1) Attend group weekly and share my progress/struggles with group
2) Attend at least 2 AA meetings per week for next 6 months
3) Find a sponsor and start working the steps in the next 2 weeks

Problem: I have used alcohol/drugs to cope with stress and anxiety

Goal: To find healthier ways to cope and deal with my stress and anxiety that won't
cause more problems.
Plans: 1) Attend group weekly and share my progress/struggles with group
2) Try meditation at least 3 times per week for 3 weeks to see if this tool will
help.
3) Exercise at least 3 times per week; I know this helps if I'm consistent
4) Talk to either my Mom, Christine or Steve when I need support; they are good
listeners and are good support for me.
 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

INTERLOCK ENHANCEMENT COUNSELING

SCREENING

1. Do you currently have an Interlock Ignition System installed on your vehicle?

 Yes  No

*If yes, do you feel it is beneficial to you?  Yes  No

2. Do you intend to have an Interlock Ignition System installed on your vehicle while you are in
treatment?
 Yes  No

3. Would you be interested in an Interlock Enhancement class that could help you complete Track B,
C or D five weeks early? (Does not apply to Track A)
 Yes  No

4. Will you keep an Interlock Ignition System installed in your vehicle longer than required to aid in
preventing future offenses?
 Yes  No

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

CHART ORDER

NAME:
IN CHART
RIGHT SIDE
CLIENT FACE SHEET
SERVICE PLAN REVIEWS RELIATRAX
ORIGINAL SERVICE PLAN RELIATRAX
APPLICATION FOR ADMISSION
APPLICATION FOR RE-ADMISSION
APPOINTMENT REMINDERS
AFFIDAVIT OF ENROLLMENT (DMV)
UPDATED BIOPSYCHOSOCIAL ASSESSMENT COUNSELOR
BIOPSYCHOSOCIAL ASSESSMENT
YOUR MASTER PROFILE
OUT OF STATE OFFENDER CLIENT QUESTIONAIRE
CLIENT PERSONAL EVALUATION
DISCLOSURE STATEMENT
CONFIDENTIALITY GUIDELINES
ACKNOWLEDGMENT OF PRIVACY NOTICE
RELEASES OF INFORMATION
INTERLOCK ENHANCEMENT SCREENING
LEGAL PAPERWORK (REQUEST FROM PO IF MISSING)
LII4+ ASSESSMENTS
IEC COMPLETION PAPERWORK/IEC MONTHLY REPORTS
MEDICAID ELIGIBILITY
MEDICAID PAPERWORK (NOT INCL. ROIs)
CONTRACT FOR TREATMENT

LEFT SIDE
CHART ORDER
PROGRESS NOTES IN ORDER OF GROUP RELIATRAX
INFECTIOUS DISEASE BEHAVIORAL SCREEN SCORE
INFECTIOUS DISEASE MEDICAL SCREEN
ADMISSION DACOD
DISCHARGE DACOD
DISCHARGE SUMMARY / REPORT RELIATRAX
DRS (DWC ONLY)

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

YOUR LEGAL AND HUMAN RIGHTS

1. You have the right to be treated with dignity, and respect, as an individual with personal needs,
feelings, preferences and requirements.

2. You have the right to privacy in your treatment, in your case, and in fulfillment of your personal
needs.

3. You have the right to be fully informed of all services available to you at the Counseling Center
and of any changes for those services.

4. You have the right to be fully informed of your rights as a patient and of all the rules and
regulations governing your conduct as a patient in the program.

5. You and your family have the right to participate in the development of your treatment plan.

6. You have the right to voice your opinions, recommendations, and grievances in relation to
policies and services offered by the program, without fear of restraint, interference, coercion, or
reprisal.

7. You have the right to refuse treatment to the extent permitted by law and to be informed of the
consequences of that right.

8. You have the right to confidential treatment of your client records. Information from your client
records will not be released without your prior written consent, except in your transfer to another
health care facility for emergency treatment or as required by law.

9. You have the right to know the name and professional qualifications of all staff members
involved with or responsible for your treatment.

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM

 North South
3489 W 72nd Ave, Ste 105 4195 S. Broadway St.
Westminster, CO 80030 Englewood, CO 80113
Phone: 720-508-4876 Phone: 303-806-0933
Fax:720-612-4239 Fax: 303-806-0935

FEE SCHEDULE

TREATMENT:
ALCOHOL AND DRUG EVALUATION $200.00
INTAKE $55.00
RE-ADMIT FEE $25.00
LEVEL II EDUCATION/THERAPY $30.00/GROUP
ANGER MANAGEMENT $30.00/GROUP
SSIC (OFFENDERS) THERAPY $30.00/GROUP
CBT RELAPSE PREVENTION $30.00/GROUP
METH RECOVERY PROGRAM $30.00/GROUP
MORAL RECONATION THERAPY $35.00/GROUP
INDIVIDUAL SUBSTANCE ABUSE COUNSELING $55.00/HOUR
PEER RECOVERY COACHING $40/HOUR

MONITORING:
7-POLY/ETG URINE ANALYSIS (NORCHEM SENTRY) $15.00
CONFIRMATION OF POSITIVE TEST $30.00
SYNTHETIC AMPHETAMINE (BATH SALTS) UA $50.00
SPICE/K2 URINE ANALYSIS $50.00
KRATOM (MYTRAGYNINE) $50.00
BREATHALYZER TESTING $5.00/TEST
ANTABUSE MONITORING PER MONTH
2X WEEKLY $20.00
3X WEEKLY $30.00
DAILY $60.00

UPDATED FEBRUARY 13, 2020

EMAIL: [email protected] WEBSITE: WWW.COUNSELINGCENTEROFTHEROCKIES.COM