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