Intake Form (1)
Client Information

Notice of Privacy and Confidentiality Practices Agreement Information

Hope’s Door is a non-profit organization that provides services to families affected by domestic violence.

Agency  Services   Include:

• Individual counseling for adults and children
• Group counseling for adults and children
• Emergency Shelter for Survivors
• Legal Advocacy Program
• Transitional Housing Program
• Battering Intervention and Prevention Program
• 24-hour Crisis Hotline: (972) 257-0057
• Counseling Center: (972) 422-2911
• Crisis Intervention
• Community Education
• Bilingual/Spanish Services
• Dating Violence Prevention Program
• Case Management

Intake

The intake process includes information about services, policies, safety planning, and an opportunity for perspective clients to inform us of their needs and services they are seeking. During and upon completion of an intake, perspective clients are assessed to determine if Hope’s Door is able to provide service. If it is determined that Hope’s Door is not able to provide service, then referrals and resources will be provided. Please note that completing an intake is not a guarantee for services at Hope’s Door.

Client Rights

It is the policy of Hope’s Door that clients and or their children have the right to:

• Safety and safety planning.
• Recognition of their interests and self-determination.
• Respect and protection of their civil and legal rights.
• Privacy and confidentiality within the required laws and regulations.
• Compassion and acceptance without opinion or judgment.
• Services provided in an empowered-based environment, without attribution of blame.
• Support by a victim’s advocate, when requested, to act on behalf of their stated needs within the social and legal parameters of this organization.
• Personalized services and information, including referrals and resources.
• Refusal of any services offered.
• Be treated with respect and dignity by staff, volunteers, interns, and board members of this organization.
• A supportive positive environment that ensures safety, respects boundaries, and values the health and well-being of every individual.
• A healthy and empowering counseling environment.

Children’s Services

The purpose of Hope’s Door’s children’s services is to support children and adolescents healing from domestic violence. Children’s reactions are varied and can range from the absence of noticeable trauma symptoms to severe adjustment disorders. The impact of abuse varies according to factors such as age, gender, support, and stage of development.

Intervention is one of the most important factors in the healing process of children after abuse has occurred. Counseling provides hope for a positive and successful future. A variety of treatment methods are used at Hope’s Door based on each child’s emotional, psychological, and developmental needs including:

• Play Therapy

• Activity/Talk Therapy

• Group Support

When children begin counseling, their behaviors may appear to worsen before they improve. As children begin to freely express themselves, significant feelings may emerge. These feelings may manifest as “acting out” behaviors and are a typical part of the counseling process. It is important for the parent and children’s counselor to be in contact if and when this occurs.

Clients who want their children to participate in children’s groups, individual counseling, play therapy, or childcare must complete a Child Brief Assessment with a counselor. The Child Brief Assessment will be reviewed and approved by Hope’s Door clinical staff. If individual counseling or play therapy will be a recommendation, as part of a child’s individual service plan, the parent must schedule a Psychosocial Assessment. The Psychosocial Assessment will be more thorough on what the child has experienced, behavior, and their current therapeutic needs. Hope’s Door must obtain an official copy to be review prior to accessing services when any custody orders are currently in place to determine whether we can provide counseling services to your children. A copy of the custody orders is required for children’s files.

Groups

Hope’s Door offers groups for children and adults. Group must be a recommendation on a client’s individual service plan treatment for clients to attend. Clients are required to agree to group rules and expectations. Please speak to the intake counselor if you are interested in groups.

 Group Expectations

• No one will be admitted in group 15 minutes after listed start time.
• Certificate of Completion will be given to all clients who successfully complete 12 weeks of group. Please see the group facilitator regarding a desire to attend additional groups.
• Please note, that after three (3) consecutive absences the number of completed group sessions will restart.
• Clients can only count 1 Domestic Violence Education group per week.
• Please turn cell phones OFF.
• No guests.
• Maintain confidentiality. What is said in group, stays in group.
• Share as much or as little about yourself as you feel comfortable.
• Speak for yourself and not others. Use "I" statements and not "we," "you," "them," and "they."
• Treat everyone with respect. No derogatory remarks.
• Everyone should listen when one person is speaking.
• Limit leaving group to emergencies only.

Group clients may not share personal contact information (phone numbers, email, etc.) with other group clients. Contact between group clients outside of group is not condoned.

Notice of Privacy and Confidentiality Practices Agreement Legal/Policy

 Ethics

All agency services will be rendered in a professional manner consistent with accepted ethical standards. All Hope’s Door counselors adhere to the Code of Ethics for which their license falls, including the Texas State Board of Examiners of Professional Counselors, the Texas State Board of Examiners of Marriage and Family Therapists, and or the Texas State Board of Social Worker Examiners.

Substance Abuse Policy

As described above domestic violence and more specifically intimate partner violence must be the presenting issue for clients to receive services at Hope’s Door. If a client presents at intake and it is determined that the client is experiencing an active substance related issue as recognized by the DSM-V substance related disorders category then, clients will be provided appropriate referrals for substance related treatment providers, which may include the completion of treatment prior to beginning any services at Hope’s Door.

Hope’s Door will not provide a “diagnosis” but is committed to providing clients with the most appropriate referral. Substance related disorders are measured on a continuum from mild to severe and are categorized by the abuse and dependence of ten separate classes of drugs: alcohol, caffeine, cannabis, hallucinogens (phencyclidine or similarly acting aryl cyclohexylamines), other hallucinogens such as LSD, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants (including amphetamine-type substances, cocaine, and other stimulants), tobacco, and other or unknown substances.

Compliance with recommendations by a substance related treatment provider, which may include completion of a substance treatment program, and thirty (30) days of sobriety are required for clients prior to beginning services at Hope’s Door. The written authorization for the disclosure of information between Hope’s Door and a substance abuse treatment provider is required to confirm compliance, consult, and coordinate a client’s individual service plan.

Hope’s Door reserves the right to assess substance abuse and or dependence during treatment. If a client appears to be under the influence of a substance on Hope’s Door premises, clients will be referred to a substance related treatment provider and services received at Hope’s Door may be terminated immediately.

If abuse or dependence of substances is observed during the course of treatment at Hope’s Door, clients will be referred to a substance related treatment provider and Hope’s Door’s clinical staff will determine and inform clients if it is appropriate for clients to continue receiving services at Hope’s Door and or if an amendment to an individual service plan is required.

If a client is under a health professionals care and or treatment and medication is prescribed and a part of a client’s treatment then Hope’s Door will require the written authorization for the disclosure of information between Hope’s Door and the client to confirm compliance, consult, and coordinate a client’s individual service plan.

Subpoena Policy

Hope’s Door will accept a subpoena delivered by a constable and/or server for records and/or appearance when subpoenaed by a court of law. Hope's Door does accept a faxed subpoena issued by a court of law. Upon receipt of a subpoena from a constable, only the person named on the subpoena can sign for it. If the subpoena is to be delivered to the Custodian of Records, only the Chief Executive Officer can sign for it. Hope’s Door will attempt to contact the client 3 times to inform of receipt of subpoena.

Client Records

Records are kept for the purpose of documenting the services you received, as well as your needs, goals, progress, and continuity of services. Hope’s Door utilizes a secure electronic filing system for your records, as well as a paper record. These records are maintained by the staff providing services. Records are retained by the agency for 7 years for adult clients. Children’s records are retained for 7 years after their 18th birthday.

Clients can complete an "Authorization for Disclosure" form that can be utilized to release confidential information to self, providers, agencies, and/or others as designated by the client. An "Authorization for Disclosure" form is maintained for up to 90 days from the date signed unless a "Cooperative Working Agreement" between agencies is completed and in effect which keeps the "Authorization for Disclosure" form is active for up to 1 year from the date signed. A client can void and or terminate an "Authorization for Disclosure" form by informing a counselor and or advocate and the "Authorization for Disclosure" form will be labeled "VOID" with the date the "Authorization for Disclosure" form was voided. The counselor and or advocate will update and notate the change on the client's "Contact Log".

Clients have the right to review, comment on, and/or receive a copy of their and or their child’s records. If a client wishes to request a copy of their record, please follow the procedure as outlined:

1. Complete a Records Request form. If you want HDNBC to share your record directly with another person or entity, outside of the name designated on the Records Request Form you will be required to sign a separate “Release of Information Form.”
2. Submit a governmental picture identification card.

Charges will be assessed as follows:

• Current clients (or their lawyer) who request their record will be charged $10 per copy per record requested.
• Clients who have not received services within 30 days of the request (or their lawyer) will be charged $20 per copy per record requested.
• Non-clients (or their lawyer) who request a record will be charged $30 per copy per record requested.
• Records for the intended purposes of transfer and/or another service provider's request are processed for FREE.

You have the right to contest any entry in the record. If you contest an entry, the Director of Clinical Services will make a notation in the case file stating that you believe the entry to be inaccurate.

You must show proof of identification (photo ID) when requesting and/or picking up records.

Please allow 10 – 15 business days for requests to be processed.

Electronic Records

Hope's Door maintains electronic entries that are secure and attributed to a client, which include password-protected system access. Records are kept in compliance with applicable state and federal laws, including the Family Violence Prevention and Services Act (42 U.S.C. Chapter 110), and §§379.504, 379.619, and 379.625 of this subchapter (relating to security policies and procedures; maintaining control over resident and nonresident files; and policies and procedures for the retention and destruction of documentation).

Safety and Security Procedures

Hope’s Door strives to maintain safety and security by utilizing intercoms and security cameras on the premises. Everyone must identify themselves before access onto the property is permitted. Hope’s Door can deny entry if an individual is perceived to be a safety and or security risk. Clients will sign in with the front reception staff and will be contacted in the foyer for their scheduled appointment. Children under the age of twelve (12) are not allowed unsupervised in the waiting room. A parent or guardian must be responsible for their children, including escorting them to the restroom, child care, and or group. A parent or guardian must remain on site and in the building while children are receiving individual and or group services.

If receiving group services, please acknowledge that only group members are allowed to participate in group. This is to protect and maintain confidentiality. If a client is accompanied by a person who is not a client of Hope’s Door, that person may wait in the lobby and or may be asked to exit the building.

Nonviolent Disciplinary Policy

Parents are responsible for the discipline of their own children. Corporal punishment (i.e. spanking, hitting, etc.) is not permitted. Parents are not allowed to discipline children other than their own.

Hope’s Door uses re-direction when attempting to correct a child’s behavior. If a child’s negative behavior continues, parents will be asked to attend to their child’s behavior.

Termination of Services

Voluntary Termination

Clients access Hope’s Door services voluntarily and may decide at any point to discontinue services.

 Involuntary Termination

Clients may be terminated from services by Hope’s Door for the following reasons and behaviors that put the safety of clients, staff, volunteers, or interns at risk. These behaviors include:

• Possession of a weapon;
• Being violent and/or abusive toward others;
• Failure to comply with referrals for mental health or medical treatment outside our expertise;
• Possessing illegal substances on site;
• Sexual abuse of clients, staff, interns, volunteers;
• Failure to comply with program policy.

Notice of your Right to Appeal if Your Services Have Been Terminated

Hope’s Door recognizes the right to appeal a decision to terminate services.

Please refer to grievance policy section for instruction on how to file a written grievance.

Clients who voluntarily or are involuntarily terminated from services will be encouraged to complete a safety plan and will be provided referrals for services outside of Hope’s Door.

Waiver of Liability

For and in consideration of Hope’s Door outreach services, I hereby release and discharge Hope’s Door, a non- profit organization, its Board of Directors, officers, employees, and volunteers of any form and all manner of claims, causes or action or demands, which I, my heirs, successors or assigns, may have hereafter connection with personal injury, theft, property damage, or any of the above consequences which could result from activities and behaviors inflicted upon me and my family by my abusive partner or anyone else while attending counseling services at Hope’s Door.

Confidentiality Agreement

Confidentiality is defined as keeping private all information confidential that is shared between a client and his or her counselor or advocate including all personal information and all communications, observations, and information made by and between or about adult and child residents and nonresidents, employees, volunteers, student interns, and board members. Counselors providing services to minors will respect this definition of confidentiality. Hope's Door acknowledges that there are limitations to maintaining confidentiality of electronic records and transmissions. Individuals might have authorized or unauthorized access to such records or transmissions even though Hope's Door utilizes password protected data storage and password protected staff email accounts.

Hope’s Door personnel may have access to your records and/or your child’s records for the purpose of supervision, case staffing, and storage of data collection in agency database. Hope's Door also maintains confidential information to maintain the safety of: victims; victims' families; volunteers; employees; and others related to the program.

Funding sources require occasional access to your records and/or your child’s records for the purpose of agency audits and billing. These individuals will also respect the privacy of your records and/or your child’s records. As a client or managing conservator of a minor, you have the right to withhold or release information to other individuals or agencies. A signed statement signed by you is required before any information may be released to anyone outside the Hope's Door staff, with the following exceptions:

When a court of law subpoenas information shared by you with your counselor and/or advocate.

Mental Health Professionals shall report if required by any of the following laws:

If abuse or neglect of minors is reported by you or your child, a report must be made to the appropriate authority. (Family Code, Chapter 261)

If abuse, neglect, or exploitation of elderly or disabled is reported by you or your child, a report must be made to the appropriate authority. (Human Resources Code, Chapter 48)

If abuse, neglect, and illegal, unprofessional, or unethical conduct by a mental health provider is reported by you or your child, a report must be made to the appropriate authority. (Health and Safety Code, Chapter 161)

If sexual exploitation by a mental health provider is reported by you or your child, a report must be made to the appropriate authority. (The Civil Practice and Remedies Code, Section 81.006)

 A mental health professional is authorized to disclose information to emergency personnel in case of danger of suicide or homicide, or release of records under court subpoena. (Health and Safety Code, Chapter 611.004)

We also evaluate how well our programs are doing by collecting information from clients. We release this information in aggregate form to our funding sources, other agencies, and the general public. The information released does not contain identifying information. This is in keeping with select federal guidelines and regulations [e.g., 28CFR22 and 28 CFT part 46 sec. 46 101 (b) 5 (i, ii, iii)].

As a non-resident client and/or parent/caregiver of a client, I agree to the following:

Guidance on House Bill (HB) 3649 Implementation

Communication between a family violence advocate and a victim of family violence is confidential, if the communication is made in the course of advising, advocating for, counseling, or assisting the victim. The victim, or certain people on behalf of the victim, may prevent others from disclosing the communication, except in limited circumstances.

Communication that is privileged may be disclosed only for the following reasons:

• To another employee or volunteer of a family violence center for the purpose of furthering the advocacy process,
• For the purpose of seeking evidence that is admissible under Article 38.49 Code of Criminal Procedure (Forfeiture by Wrongdoing), following an in-camera review and determination that the communication is admissible,
• To other persons in the context of a support group or counseling that the victim is participating in, and
• For the purpose of making a report under Chapter 261 of the Family Violence Code (report of child abuse or neglect), or Section 48.051, Human Resources Code (reports of abuse, neglect, or exploitation of elderly or disabled).
• If the family violence center, at the request of the victim, discloses a communication privileged for the purpose of a criminal or civil proceeding, the family violence center shall disclose the communication to all parties to that criminal or civil proceeding.

For more information, please see reference: http://www.legis.state.tx.us/tlodocs/85R/billtext/html/HB03649F.htm

Notice of Privacy and Confidentiality Practices Agreement Additional Information

Nondiscrimination Statement

Hope’s Door complies with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, American Disability Act of 1990, and the Health and Safety Code relating to workplace and confidentiality guidelines regarding AIDS and HIV. Individuals will not be discriminated against on the basis of sex, age, race, color, political beliefs, sexual orientation, national origin, religion, or physical disabilities.

Hope’s Door understands that due to American for Disabilities Act requirements, Hope’s Door staff, volunteers, and interns may not receive and/or ask clients to notify Hope’s Door of having HIV/AIDS or any other protected illness or disability. If you think you have been discriminated against, contact immediately:

Civil Rights Office

Health and Human Services Commission

701 W. 51st Street, MC W206 Austin, Texas 78751

1-888-388-6332 or 1-512-438-4313

TTY toll-free: 1-877-432-7232

HHSCivilRightsOffice@hhsc.state.tx.us

Client Grievances/Complaints

Hope’s Door strives to provide a safe and supportive environment in our programs. If a client feels they are being treated unfairly or in a less than supportive manner, clients are encouraged to address those issues with the party involved. If the response is deemed inadequate or unacceptable, clients may file a grievance to address their concerns. A copy of the grievance should be submitted in writing and will be reviewed by the Clinical Director.

The Clinical Director will respond to the grievance in writing within five business days of receipt of the grievance. The Clinical Director will work with the client regarding their concerns.

If the client feels the problem has not been resolved to their satisfaction, the client may request to meet with the Clinical Director. The Clinical Director will meet with the client within five working days of receipt of a meeting request. The Clinical Director will issue a response in writing, regarding findings five working days after the meeting.

If a client has a complaint about any staff member who is licensed by the State of Texas to practice counseling, you may file your complaint with the appropriate licensing board, either the Texas State Board of Examiners of Professional Counselors, the Texas State Board of Examiners of Marriage and Family Therapists, or the Texas State Board of Social Worker Examiners:

Professional Licensing and Certification Unit

Texas Department of State Health Services

Mail Code 1982

P.O. Box 149347

Austin, Texas 78714-6628

(512) 834-662

Staff Qualifications & Fees

Counseling will be provided by counselors and social workers who are either fully licensed, have obtained their master’s degree, or are in the process of completing their master’s degree. All unlicensed counselors and social workers receive supervision by a licensed counselor or social worker. Advocates have at least a bachelor’s degree in counseling, social work, or a related field. All survivor services provided at Hope’s Door are free of charge with the exception of some legal services.

Cancellations and No-Shows

In the event a client needs to cancel a scheduled and or reoccurring appointment, Hope’s Door requires 24 hours advanced notice. If a client fails to attend a scheduled and or reoccurring appointment without 24 hours advanced notice, the non-attended appointment is considered a “no call, no show.” If a client “no call, no shows” a scheduled and or reoccurring appointment, the client is responsible for contacting Hope’s Door to reschedule. Counselors are not always available to reschedule during the same week.

If you have a reoccurring appointment (such as for individual counseling), after two consecutive “no call, no shows,” Hope’s Door will no longer reserve your reoccurring appointment day and time. Extenuating circumstances will be considered if communicated in a timely manner.

Office Closure

In the event that Hope’s Door’s office must close unexpectedly (such as for inclement weather), we will display notification on our website (www.hopesdoorinc.org). Hope's Door will attempt to notify clients of unexpected closure to reschedule if clients have a reoccurring and or scheduled appointment for that day. If a client planned on attending a counseling group and there is inclement weather, please call our office at 972-422-2911 or visit our website to see if the office has closed.

Please note that Hope's Door’s office is closed when Plano ISD cancels classes during inclement weather.

About Counseling & Advocacy

Hope’s Door believes that clients have the ability to resolve their own problems. While the counselor or advocate may offer tools for change, it is the client’s choice to use the tools. Clients have the right to refuse or negotiate modification of any techniques that clients believe may be inappropriate for them or their child. Clients also have the right at any time to discuss the positive and negative effects of counseling with a counselor. Services are voluntary and clients may discontinue services at any time. Should clients and/or a counselor believe that a referral is needed, appropriate referrals, including interagency referrals, will be made. It is a client’s responsibility to pursue referrals and recommended resources.

Potential Benefits of Counseling:

• Increased self-awareness and education about domestic violence, relationships, and choices in a client’s life.
• Opportunities to develop and practice new skills in a supportive environment.
• Support in reaching personal goals.
• Increased safety planning skills.

Potential Risks of Counseling

Participation in counseling may contribute to a client’s choice to change some of their behaviors. There is a potential risk that significant others in a client’s life may not be supportive or approving of the changes a client chooses to make. Both personal safety and personal choice will be emphasized throughout the counseling experience.

Personal growth sometimes includes periods of discomfort. Participation in counseling may contribute to remembering difficult events and experiencing intense feelings. A counselor can be a resource during these times by helping clients establish individualized safety plans and coping skills.

Attempts to Schedule Appointments

If Individual counseling is part of a client’s individual service plan, Hope’s Door will attempt up to three times to contact a client to schedule individual counseling. If Hope’s Door does not confirm an appointment with a client within three attempts or if we are unable to contact a client using the contact information provided at intake, it is not the responsibility of Hope’s Door to continue trying to schedule individual counseling.

Case Management and Legal Advocacy will also follow the same procedure above in attempting to contact clients to schedule appointments.

Correspondence & Communication

Hope's Door acknowledges that electronic correspondence (email) is a form of communication that presents benefits and limitations. Contact through electronic correspondence may be interrupted and or accessed by individuals not intended to receive the electronic correspondence. Hope's Door staff are only available to access and respond to electronic correspondence during regular business hours (Monday – Friday, 9:00 AM to 5:00 PM). Emergencies experienced by a client should be directed to 911 and or emergency service providers and not through electronic correspondence. Non-life-threatening emergency crisis calls can be made to the Hope’s Door 24/7 hotline at (972) 257-0057.

Communication such as Google voice, Google talk, or any other call management applications or providers is prohibited between clients and Hope’s Door staff or affiliates during or after business hours (Monday-Friday, 9:00 AM to 5:00 PM).

Access to Records

Telehealth/Telemental Health Services Consent Form

Telehealth/Telemental Health Services: Hope’s Door New Beginning Center (HDNBC) uses the term “Telehealth or Telemental health” to describe a therapist or counselor who provides psychological counseling and support over the internet through email, video conferencing, or a phone call.

Please read the following video therapy consent and sign below: