Intervention only

Agency Information & Hours of Operation

GYG Mental Health (GYG) is a community-based mental health agency licensed to operate in the Commonwealth of Virginia. GYG is strength based, community based service provider, that will adhere to all Virginia Department of Behavioral Health and Developmental Services regulations and maintain secure, confidential documentation on each client.

Our Mission Statement:

GYG Mental Health Agency believes that every child and their family deserves the right remain intact. It is also our belief that every family has the right when receiving services to be treated with dignity and respect. Therefore, as an agency we are dedicated to providing a service that is individualized, therapeutically appropriate with the highest levels of accountability and quality, which shall be offered to all children and families without exception. GYG Mental Health Agency shall also be dedicated to teaching families the needed skills to assist as well as ensure family preservation and assist in the reunification of children and families.

GYG services provided shall include, but are not limited to the following: crisis treatment, individual and family counseling, communication skills for appropriate problem-solving, anger management, interpersonal interaction, case management activities, educational assistance, out – patient clinical services as well as coordination with other involved services, and 24-hour emergency response .

GYG is located at 809 Main Street Suite 100 Newport News, Virginia 23605; our office number is 757.595.8008, our fax number is 757.595.8802 and our website address is www HYPERLINK "http://www.guidingyounggirls.com". HYPERLINK "http://www.guidingyounggirls.com"guidingyounggirls HYPERLINK "http://www.guidingyounggirls.com". HYPERLINK "http://www.guidingyounggirls.com"com . GYG’s office hours are 9am to 5pm, Monday thru Friday; GYG’s after hour emergency number is 757.240.9359.

All counselors shall meet the DMAS employment eligibility requirements as either an Quality Mental Health Professional (QMHP), Licensed Mental Health Professional (LMHP) and/or be licensed eligible.

We thank you for the opportunity to service your child and family and sincerely believe that we can bring about change, instill hope and change the world through “using a holistic family approach to change the world one family at a time.”

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Mission Statement

“Using a Holistic Family Approach to Change the World One Family at a Time”

GYG Mental Health Agency (GYG) is a community-based mental health agency licensed to operate in the Commonwealth of Virginia. GYG is strength based, community service provider, which will adhere to all Virginia Department of Behavioral Health and Developmental Services regulations and maintain secure, confidential documentation on each client.

GYG services provided shall include, but are not limited to the following: crisis treatment, individual and family counseling, communication skills for appropriate problem-solving, anger management, interpersonal interaction, case management activities, educational assistance, out – patient clinical services as well as coordination with other involved services, and 24-hour emergency response .

Our Mission Statement:

GYG Mental Health Agency believes that every child and their family deserves the right remain intact. It is also our belief that every family has the right when receiving services to be treated with dignity and respect. Therefore, as an agency we are dedicated to providing a service that is individualized, therapeutically appropriate with the highest levels of accountability and quality, which shall be offered to all children and families without exception. GYG Mental Health Agency shall also be dedicated to teaching families the needed skills to assist as well as ensure family preservation and assist in the reunification of children and families.

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

HIPPA Policy

(Give to Client and Family – Copy)

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Why We Have This Privacy Notice

We are required by law to maintain the privacy of protected health information, and to provide you with notice of our legal duties and our privacy practices with respect to this protected health information. Also, we must abide by the terms of this Notice. If we make any changes in the Notice, we must notify you before the change can take effect. We reserve the right to change the terms of this Notice and to make any new Notice provisions effective for all protected health information that we maintain. You will be asked to acknowledge that you have received this Notice, and you have a right to have a hard copy of this Notice.

In order to effectively provide services to individuals GYG Mental Health Agency must utilize and in some cases disclose information about individuals receiving services. We must do that in order to provide services. This Notice explains how we may use and disclose information about you. It also describes your rights to see, amend, and control your “protected health information”(PHI), which is defined as “information related to your past, present or future physical or mental health or condition and related health care services, including demographic information that may identify you..” This Notice is about the use and disclosure of your “PHI”. Sometimes the word” information” or the word “record(s)” or the phrase “medical record(s)” will be used. When they appear in this Notice, they mean the same thing as “PHI”. The word “individual”, when used in this notice, refers to you and other clients of GYG Mental Health Agency. If you have any questions about this Notice, or about any of GYG Mental Health Agency privacy policies, procedures or practices, please call us at (757-595-8008), and ask to speak with our Privacy Officer.

Permitted Uses and Disclosures of Protected Health Information without the Written Authorization of the Individual: Treatment, Payment and Health Care Operations. Medical privacy laws try to make sure that the protection of your privacy does not interfere with your ability to get treatment. Therefore, the law allows us to use and disclose your protected health information, without asking for your prior authorization, for the following purposes:

For treatment purposes: Your protected health information may be shared among staff and consultants of the GYG Mental Health Agency as part of the treatment process.

EXAMPLE: A therapist may speak to their supervisor about the need for medication. During those consultations, health information about you will be shared. Your protected health information may be shared with another treatment provider who is treating you. EXAMPLE: if you had to go to the hospital and your treating physician there asked GYG Mental Health Agency staff about medications you are taking, that information could be shared with your treating physician to help that physician give you better care.

For payment purposes: In order to get paid for providing treatment to you, GYG Mental Health Agency must send some treatment information about you to the company (such as your health insurance company) that is responsible for paying for that treatment. Such companies have a right to review treatment information about you to make sure that the treatment meets their standards for payment. Therefore, we may use information about you to arrange for payment (for example, preparing bills and managing accounts), and we may disclose information to others (such as insurers, collection agencies and consumer reporting agencies) to get payment. GYG Mental Health Agency will provide only the “minimum necessary information” required by such companies for us to get paid.

EXAMPLE: The Department of Medical Assistance Services (which administers Medicaid) pay for treatment provided to some clients of GYG Mental Health Agency. DMAS has the authority to review the treatment records of clients to make sure that treatment meets their standards.

For Health Care Operations: There are a numerous ways in which your protected health information must be used and disclosed by GYG Mental Health Agency staff in order to carry out a variety of program activities that are called “health care operations”. These operations are needed to help us to, for example, review and improve the quality of our services and find more effective and efficient ways to serve you.

EXAMPLES: Our professional staff reviews treatment records to make sure that they are accurate, complete, and organized. This is part of our quality assurance program. In addition, we may review treatment records if necessary in taking disciplinary or other corrective action toward a staff person who has not performed properly. Those records may also be reviewed in grievance hearings about such disciplinary or corrective action.

We conduct medical, financial, and legal audits and reviews of our practices and records to make sure that we are doing our job right. Different staff may be involved in reviewing your record as part of this process. We also cooperate with outside organizations that review treatment records to evaluate, certify or license our staff or our program. In addition to GYG Mental Health Agency staff, the GYG Mental Health Agency may receive help in its health care operations from other persons, such as our attorney. It may also contract with professionals in other organizations to help. These persons and departments are required to keep confidential any protected health information they receive in doing this work. We sometimes provide training programs for students, trainees and others to help them practice or improve their skills.

Other Permitted Uses and Disclosures of Protected Health Information Without Written Authorization of the Individual.

Required by law: We may use and disclose information about you whenever we are required by law to do so. There are many federal and state laws that require us to use and disclose information about individuals receiving services from us. We will comply with those requirements, and will limit the information we provide to what is required by law.

EXAMPLES: Virginia law requires us to report to certain persons or agencies if an individual who is receiving services threatens to harm another individual. We are required by Virginia law to report to the local department of social services information that we have that leads us to suspect that a child has been abused or neglected.

We are licensed by the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS). And they require GYG Mental Health Agency to release your PHI to the DMHMRSAS, but also require the DMHMRSAS to implement procedures to protect the confidentiality of this information.

Public Health authorities: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. These disclosures normally are made for such purposes as preventing, controlling or investigating diseases and injuries to persons, and monitoring drugs or devices regulated by the Food and Drug Administration (FDA)

EXAMPLES: We may also be required to report information that you have been exposed to a communicable disease. For the purpose of preventing or controlling disease, injury or disability we are required to report certain information to the Health Department. This includes vital events such as death.

Health oversight activities: Virginia statutes have set up a number of agencies and offices that monitor treatment providers like GYG Mental Health Agency to make sure that they are providing proper care and are complying with the law. These and other agencies may also monitor insurance companies and others who may pay for our services. These agencies and offices have the authority to review treatment records of individuals as part of their oversight of providers.

EXAMPLES: The Virginia Office of Protection and Advocacy (VOPA) was created by the Virginia General Assembly as an independent body that monitors the treatment of persons with disabilities in different settings, including treatment settings. They have the right to review the records of individuals receiving treatment services as part of their job to ensure that these individuals are being treated right.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, to the extent that the order requires us. We may also respond to subpoenas, discovery requests or other lawful process, but in those cases the persons seeking the information must meet certain legal requirements to protect the records. Our normal practice is to contact you whenever we receive a subpoena or order to disclose your records.

Law Enforcement: We may disclose information about you to a law enforcement official for certain specific law enforcement purposes.

EXAMPLE: We may disclose information about you to a police officer if the officer needs the information to help find or identify a missing person or to catch a criminal suspect.

serious threats to health or safety: We may disclose information about you if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, but only to persons who may be able to prevent or lessen the threat.

Coroners, Funeral Directors, and Organ Donation: We may disclose information about you to a coroner, medical examiner, or funeral director, or to organizations that help with organ, eye and tissue transplants.

Research: We may disclose information about you to researchers when their research has been approved by an institutional review board that has approved the research and has required the researchers to protect the privacy of your information.

Military activity and National security: Under certain conditions, we may disclose information to military authorities about individuals receiving services from us who are in the military. We may also disclose information to authorized federal officials for national security and intelligence activities.

Inmates: If you are an inmate in a correctional or detention facility, we may disclose information about you to that facility for certain treatment and safety purposes.

Workers’ Compensation: We may disclose information about you in order to comply with workers’ compensation laws.

Secretary of Health and Human Services: We must disclose information as required by the Secretary of U.S. Department of Health and Human Services for purposes of making sure that we are complying with the Privacy Rule developed under the Health Insurance Portability and accountability Act (HIPAA).

Enhancing Your Healthcare: Some of our programs use and disclose your information in order to provide the following support to enhance your overall health care:

· Appointment reminders by call or letter

· Providing information about health-related benefits and services that may be of interest to you

Uses and Disclosures of Protected Health Information in Which You Have an Opportunity to Agree or Object

Involvement by Others in Individual’s Care: We may disclose information to a family member, other relative, close personal friend or other person you identify, IF that information is directly related to such person’s involvement in your treatment or payment for your treatment.

EXAMPLE: You ask that your sister be present at a meeting with your treating clinician. We may also let them know where you are or if something has happened to you. Usually, this will be done only if you are present and do not object. In some situations (for example, picking up a prescription for you), this disclosure may be made without your being present. You may ask us at any time not to disclose information about you to persons involved in your care.

We will follow your request, except in limited circumstances (such as emergencies). Our usual practice is to get your written authorization to disclose information to others.

Disaster Relief: We may use or disclose information about you to an agency providing disaster relief in cases where their help is needed. We will try to get your permission before doing this.

Other Uses and Disclosures of Your Information: Written Authorization Required

Other uses and disclosures of information not covered by this Notice or the laws that apply to GYG will be made only with your written authorization. If you authorize us to use or disclose information about you, you may revoke that authorization at any time. That authorization must be in writing and must be given to your treating counselor, or the Privacy officer, before it becomes effective. If you revoke your authorization, we will stop using or disclosing the information that was covered in your authorization (unless we have independent legal authority to use or disclose it). When you revoke an authorization to disclose information, we cannot take back any disclosures we have already made with your authorization.

· Your Rights to Your Protected Health Information There are several rights concerning your health information in the medical record that we want you to be aware of:

· You have the right to request access to your medical record in order to inspect it or make copies. However this right is not absolute. You cannot access information compiled in reasonable anticipation of or for use in a civil, criminal or administrative action or proceeding. Due to federal regulations access to certain information under the Clinical Lab Improvements Amendments is prohibited. We can deny you access to your medical record in certain limited situations, such as if your treating physician has made a written determination in your record that providing you access to your medical record would endanger your life or physical safety. You have the right to request review of such denial, and to have your lawyer or another physician receive the record. Within 15 calendar days after the receipt of your written request for access, we will provide you with access to your record. The charge for making any copies you desire is $.50per page and staff time if it takes more than 15 minutes to retrieve and copy the information requested. Your request to review, inspect, copy or amend your record will be kept confidential. For more information, please contact the GYG Mental Health Agency Privacy Officer, whose name, address and phone numbers are listed below.

· You have the right to request an amendment to your medical record. If you believe that GYG has information about you that is inaccurate or incomplete, you have the right to request we amend that information and notify others about it. Your request must be in writing, and should include exactly what amendment you are requesting and the reason which supports an amendment. Within 60 days after the receipt of your request we will either notify you that the amendment has been accepted and ask you to identify the relevant persons to be notified, or we will provide you with a letter indicating that your request has been denied. If your request to amend your record was denied you will receive a letter with the following: 1) an explanation of why your request was denied, 2) instructions on how to submit a written statement disagreeing with the denial, and 3) information about the person(s) with whom you may lodge a complaint about the denial. You can ask that your request for amendment and its denial be included with any past and/or future disclosures of the portions of the record that are the subject of the amendment request. You may contact your counselor GYG Mental Health Agency Privacy Officer (whose name, address and phone number are listed below) about amending your record.

· You have the right to receive an accounting of certain of the GYG Mental Health Agency disclosures of your medical record. GYG Mental Health Agency is required by the Human Rights regulations and by the HIPAA Privacy Rule to make and maintain a written accounting of certain disclosures of your protected health information. Upon written request, you have a right to receive that written accounting of those disclosures. Under HIPAA, we must keep an accounting of information released during the prior six years, but are not required to account for releases made prior to April 14, 2003. You must submit your request for an accounting to your counselor or GYG Mental Health Agency Privacy Office (whose name, address and phone number are listed below). The request must state the time period that you want the accounting to cover.

· You have the right to ask for a restriction with regard to the use or disclosure of your medical record. You have the right to request that we limit the use and disclosure of protected health information about you for treatment, payment and health care operations. We are NOT required to agree to your request. If we do agree to your request, we will follow your restrictions (except where the information is needed for emergency treatment). You can cancel the restrictions at any time. We can cancel the restrictions at any time, as long as we notify you of the cancellation, and apply the restrictions to information that was collected before the cancellation.

· You have the right to request an alternative method of being contacted. Normally, GYG Mental Health Agency staff will send letters, bills, updates, or other information to you at your home, and may call you at home to schedule or remind you of appointments or to obtain needed information from you. You have the right to request that we communicate with you about treatment matters in a certain way or at a certain location. For example, you can ask that we contact you at work, or only by mail.

· You have the right to a paper copy of this Notice. You have the right to receive a paper copy of this notice at any time, even if you agreed to receive this notice electronically. You can get an electronic copy of this Notice at our website, www.guidingyounggirls.com. To obtain a paper copy of this Notice, talk with or write to your counselor or the GYG Mental Health Agency Privacy Officer (whose name, address and phone number are listed below).

· You have a right to file a complaint or ask for additional information about our privacy policy. If you feel that any of your privacy rights has been violated, or if you would like additional information concerning our privacy policy, or the federal and state laws pertaining to privacy, please contact any of the persons listed below. We will not take action against you or change our treatment of you in any way because you file a complaint. You may contact any of the following persons:

Daniel R. Brown Reginald Daye

GYG Mental Health Agency Regional Human Rights Advocate

809 Main Street Suite 100 Eastern State Hospital Satellite Office

Newport News, Virginia 23605 P.O. Box 8791

757-595-8008 Williamsburg, Virginia 23187-8791

757-253-7061

Secretary of the Department of Health and Human Services

1800 F Street NW

Washington, DC 20405

www . HYPERLINK "http://www.dhhs.gov"dhhs HYPERLINK "http://www.dhhs.gov". HYPERLINK "http://www.dhhs.gov"gov

(NOTE: Complaints to the Secretary of HHS should be made no later than 180 days after the privacy violation occurred or you became aware (or reasonably should have been aware) that the privacy violation had occurred. This time limit may be extended for good cause.)

A complaint can be made in person, over the phone or by mail.

Alcohol and Drug Abuse Information

The privacy of information held by GYG Mental Health Agency which identifies, or could identify, a person as an alcohol or drug abuser, is controlled by a specific federal privacy law. The privacy standards of 42 CFR Part 2 (authorized by 42 U.S.C. 290dd-3and 42 U.S.C. 290ee-3) are often more restrictive than the standards set out in this Notice, and we must follow the more restrictive standards. Generally, GYG Mental Health Agency may not say to a person outside the program that you attend the program, or disclose any information identifying you as an alcohol or drug abuser unless: (1) you authorize it in writing; (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Violation of Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by an individual or against any person who works for GYG Mental Health Agency or about any threat to commit such a crime. They also do not protect against any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

Minors

Under Virginia law, minors are deemed to be adults for purposes of giving consent to outpatient treatment for mental health services. Under federal law (42 CFR Part 2), a minor who becomes a patient for substance abuse treatment has the same authority as any adult patient in regard to the privacy of his or her treatment records. The minor’s parents, guardian, or legal custodian can have access to treatment records only with the minor’s permission. However, in the case of a minor who is receiving outpatient mental health services, the minor’s parents, guardian, or other legal custodian also have a right of access to the minor’s records. There are certain narrow exceptions in which a parent, guardian, or other legal custodian can be denied access to a minor’s records.

Personal representative

When an individual is incapacitated or otherwise unable to give informed consent to treatment or authorization for the disclosure of records, that person’s “personal representative” may exercise the authority of the individual in regard to the privacy of the individual’s records. A “personal representative” is a person authorized under Virginia law to give substitute authorization for the individual, such as a guardian, attorney-in-fact, or, under certain circumstances and procedures, a family member or other person designated as a “legally authorized representative” under Virginia’s Human Rights regulations. However, the individual must be included in decisions about disclosing information, to the extent that the individual is able, and, unless the personal representative is a guardian with specific authority to act, any objection by the individual to a disclosure of records, even if the personal representative approves, must be reviewed before we can disclose the information. Finally, a personal representative’s access to an individual’s information can be denied if a licensed health care professional determines in the individual’s record that such access by the personal representative is reasonably likely to cause substantial harm to the individual or to another person.

Changes to Privacy Practices

GYG Mental Health Agency reserves the right to change any of its privacy policies and related practices at any time, as allowed by federal and state law. You will receive notice of changes in one or more of the following ways: mail; discussion with an agency representative; electronically; a notice prominently posted in a public area, such as the waiting room.

EFFECTIVE DATE: February 11, 2011

Client’s Signature: ______________________________________________________________

Parent/Guardian: _______________________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. Guiding Young Girls is committed to protecting this medical information, which may identify you and relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices describes how we may use and disclose your medical information in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your medical information.

GYG is required by law to maintain the privacy of medical information and to provide you with notice of our legal duties and privacy practices with respect to medical information. We are required to abide by the terms of this Notice of Privacy Practices. GYG reserves the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all medical information that we maintain at that time and a revised Notice of Privacy Practices by providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

For Treatment - Your medical information may be used and disclosed by those outside of GYG who are involved in your care for the purpose of providing, coordinating, or managing your mental health care treatment and related services with your authorization. Providing effective quality care also includes consultation with clinical supervisors or other treatment team members.

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

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

Substance Abuse Information . All medical information regarding substance abuse is kept strictly confidential and disclosed only in accordance with federal regulation (42 CFR part 2). The federal rules prohibit disclosure of this information unless expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42 CFR part 2. Disclosure of any medical referencing alcohol or substance abuse may only be made with your written permission.

Required by Law. Under the law, GYG must make disclosures of your medical information to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.

Abuse and Neglect Judicial and Administrative Proceedings

Emergencies Law Enforcement

National Security Public Safety (Duty to Warn)

Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

· Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or health department)

· Required by Court Order

· Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

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

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

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding your personal medical information maintained by our GYG. To exercise any of these rights, please submit your request in writing to our Privacy Officer, Daniel Brown :

1. Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy medical information that may be used to make decisions about your care. Your right to inspect and copy medical information will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.

2. Right to Amend. If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment.

3. Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your medical information. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

4. Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your medical information for treatment, payment, or health care operations. We are not required to agree to your request.

5. Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

6. Right to a Copy of this Notice. You have the right to a copy of this Notice.

7. Electronic Transactions Standards. All electronic transmissions follow GYG established security guidelines necessary to protect your confidentiality.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing through ​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Daniel Brown, our Privacy Officer, at (757-595-8008). If GYG is unable to satisfactorily resolve your concern, you have the right to file a complaint with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling (202) 619-0257. Your clinical care with GYG will not be compromised if a complaint is filed. This notice will be reviewed with you upon initiation of services and will be in effect as of that date.

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Notice of Client Rights

It is your right to:

1) Retain your legal rights as provided by state and federal law.

2) Receive prompt evaluation and treatment or training about which you are informed insofar as you are capable of understanding.

3) Be treated with dignity as a human being and be free from all forms of abuse.

4) Not be the subject of experimental or investigational research without your prior written and informed consent or that of your authorized representative.

5) Be afforded an opportunity to have access to consultation with a private physician at your own expense, and in the case of hazardous treatment or irreversible surgical procedures have, upon request, an impartial review prior to implementation, except in case of emergency procedures required for the preservation of your health.

6) Be treated under the last restrictive conditions consistent with your condition and not be subjected to unnecessary physical restraint and isolation.

7) Be allowed to send and receive sealed letter mail.

8) Have access to your medical and mental records and be assured of their confidentiality, but notwithstanding other provisions of the law such a right shall be limited to access consistent with your condition and sound therapeutic treatment.

9) Have the right to an impartial review of violations of the rights assured under this section and the right to access to legal counsel.

10) Be afforded appropriate opportunities, consistent with your capabilities and capacity to participate in the development and implementation of your individualized services plan.

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Please note that you are also entitled to a copy of the document entitled “How to File a Human Rights Complaint.”

Assurance of Client’s Rights

GYG Program consumers/families will be informed at intake and annually of their Human Rights. GYG shall advise all consumers/families of rights and increase probability of respect and dignity for all persons involved in the program.

Every GYG consumer and family, at intake, will sign a policy outlining Human Rights. This policy will be explained by designated program staff and will include the following Bill of Rights:

1. The Consumer has the right to choose a provider of their choice at anytime they are receiving any service.

2. The consumer has the right for recognition, respect and dignity as a human individual regardless of source (s) of financial support.

3. The consumer has the right to use his/her preferred or legal name.

4. The consumer shall retain his/her rights as provided by State and Federal law.

5. The consumer has the right to participate in his/her plans for treatment, which shall be explained in terms (in a manner) consumer may understand. The consumer has the right to an individual service plan with periodic review.

6. The consumer has the right to and will be informed of the procedure to access and provide corrections to his/her own service records.

7. The consumer has the right to refuse treatment to the extent permitted by law, and to be informed of the correspondences of this action. The consumer has the right to an adequate number of competent, qualified, and experienced staff supervising and implementing the service plan.

8. The consumer has the right to continuity of care, including appropriate follow-up care, planned and initiated by the time of discharge.

9. The consumer has the right to be informed of the use of one-way mirrors, tape recorders, audio-visual or data processing equipment which may be used in a therapeutic process prior to it’s use. No information gained by the above shall be disclosed at any time (current or future) without prior written consent of the consumer except as required by law.

10. The consumer has the right to confidentiality.

11. The consumer has a right to a safe environment.

12. The consumer has the right not to be the subject of experimental or investigative research.

13. The consumer has the right to be treated under the least restrictive conditions consistent with his/her condition and not be subjected to physical restraint and seclusion.

14. The consumer has the right to have access to his/her records and be assured of their confidentiality but, not withstanding other provisions of law, such right shall be limited to access consistent with his/her condition and sound therapeutic treatment. Access to records may be restricted in those cases where the program believes such access to be contraindicated based on the consumer’s emotional functioning. The rationale for limiting access is clearly documented in the consumer’s record.

15. The consumer has the right to provide corrections to his/her record.

16. He consumer has the right to be informed of the cost of services rendered.

17. The consumer has the right to be informed of the counseling staff responsible for his/her care, and those staff member’s professional status and staff relationship.

18. The consumer has the right to be informed of the source of the program’s reimbursement and any limitations placed on duration of services.

19. The consumer has the right to be informed of any change and the reasons for such change in the staff responsibilities for the individual, or any transfer of the individual within or outside the program.

20. The consumer has the right to be informed of the rules and regulations of the program applicable to his/her conduct and to be informed of his/her rights within the program that can be easily understood.

21. The consumer has the right to informed consent, written, dated and signed to the following:

a. Voluntary admission to the program;

b. The release of confidential information;

c. The use of audio-visual equipment;

d. Discharge plans;

22. The consumer has the right not to work or provide services for the agency.

23. If the consumer feels that his/her rights have been abridged or violated, then he/she may notify the Family Redirection Institute, Inc. Advocate either verbally or in writing. It is the responsibility of the Advocate to handle the matter in a therapeutic fashion.

24. You may file a complaint with any program supervisor if your believe any of your rights under the Community Regulations has been violated. You have the right to meet with the program supervisor investigating the complaint, and you may appeal the decision of the program director to the Local Human Rights committee (LHRC).

Regional Advocate: GYG Mental Health Agency Advocate is:

Reginald T. Daye Daniel R. Brown

Eastern State Hospital 809 Main Street Suite 100

Bldg. 33 Room 147, Drawer A Newport News, Virginia 23605

Williamsburg, VA 23187 Phone: (757) 595-8008

Phone: (804) 253-5461

(804) 786-3988

On ___________________, I received a copy of the client’s Assurance of Rights and was given an opportunity to discuss these with staff.

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Medicaid Appeal Process

As a Medicaid recipient you have the right to appeal any change in treatment including the termination of services. Any appeal must be made in writing by notifying:

Appeals Division, Department of Medical Assistance Services

600 East Broad St., Suite 1300

Richmond, VA 23219

This written request for an appeal must be filed within thirty (30) days of termination. If you file an appeal before the termination date, services may continue during the appeal process. However, if the Appeals Division denies your appeal and you receive services after the termination date, you will be required to reimburse the Medical Assistance Program for services provided after the termination date.

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Area Medicaid Provider Receipt

Client Name: ___________________________ Date: ______________________

Client Number: ______________________________

I, ___________________________, have been informed that there are other Medicaid providers in my area, and I have chosen Guiding Young Girls.

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

How To File a Human Rights Complaint

TERMS YOU SHOULD KNOW:

Complaint – An allegation, made by or on behalf of a client, that there has been a violation of The Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers of Mental Health, Mental Retardation, and Substance Abuse Services.

Human Rights Advocate – A person employed by the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) to help clients exercise their rights, including their rights to file a complaint.

Local Human Rights Committee (LHRC) – A committee of at least five persons that, among other duties, holds hearings regarding clients’ complaints. At least a third of the membership includes individuals who are receiving mental health, mental retardation, or substance abuse services or have received such services within the five years preceding their appointment and family members of such individuals. Other members are professionals in the fields of mental health, mental retardation, or substance abuse services. No member may be an employee of DMHMSAS or a service provider over which the LHRC has oversight responsibilities.

State Human Rights Committee (SHRC) – A committee of at least nine persons that, among other duties, decides appeals from the decisions of the LHRC. Its membership also includes individuals who are receiving mental health, mental retardation, or substance abuse services or have received such services with the five years preceding their appointment.

HOW YOU CAN CONTACT THE HUMAN RIGHTS ADVOCATE

Your Regional Human Rights Advocate is ___Reginald Daye___________________

Phone Number: _(757) 253-7061________________________________________

INFORMAL COMPLAINT PROCESS

A client or person acting on his behalf may seek an informal resolution of a complaint. However, the client may choose, instead, to pursue the formal complaint resolution process without first pursuing the informal one. The steps are:

1) Report the alleged violation to the GYG Director;

2) The GYG Director attempts to resolve the complaint immediately;

3) The Director refers any complaint that is not resolved within five days to the Human Rights Advocate; and

4) The client or person acting on his behalf may, at any time, pursue a formal complaint.

FORMAL COMPLAINT PROCESS

The steps of this process are:

1) The client or person acting on his behalf reports the complaint to the GYG Director or Human Rights Advocate, or both;

2) The GYG Director attempts to resolve the complaint by meeting within twenty four hours with the client, any representative the client chooses, the Human Rights Advocate, and any other persons, as needed, and by conducting an investigation, if necessary;

3) The GYG Director gives the client and his representative a written decision and action plan within ten working days of receiving the complaint;

4) If the client is not satisfied, the client responds in writing to the Director’s decision within five working days;

5) The Director may investigate further;

6) The Director gives a final, written decision and action plan to the client, his chosen representative, and the Human Rights Advocate within ten working days of receiving the client’s written response.

7) The client, within ten working days of the Director’s final decision and with the help of the Human Rights Advocate or any other individual, may file a written petition to the LHRC requesting a hearing;

8) The LHRC holds a hearing within fifteen working days of receiving the petition;

9) The client and the Director may present witnesses and other evidence;

10) The LHRC, within ten working days of the hearing, makes written findings and recommendations;

11) Within five working days of the LHRC findings, the Director prepares a written action plan in response to the LHRC findings;

12) If no one, including the client, his chosen representative, the Human Rights Advocate, or the LHRC, objects to the Director’s action plan, it is implemented;

13) If anyone objects and the Director does not resolve the objection, the client may appeal to the State Human Rights Committee.

SPECIAL PROCEDURES FOR EMERGENCY LHRC HEARINGS

The steps of this process are:

1) If the Human Rights Advocate finds that there is a substantial risk that serious and irreparable harm will result if a complaint is not resolved immediately, the LHRC holds a preliminary hearing within seventy-two hours;

2) At the end of the hearing, the LHRC makes preliminary findings and recommendations;

3) The Director prepares and carries out an action plan within twenty-four hours;

4) If the client or Human Rights Advocate objects to the action plan, the LHRC holds a full hearing within five working days of the objection

OTHER VARIATIONS OF THE COMPLAINT PROCESS

The above-described processes vary in cases where it is alleged that a client has been abused, exploited, or neglected, cases where discrimination is alleged, and in some cases involving consent to treatment, human research, or disclosure of information. However, in each of these kinds of cases, the client is entitled to request a decision from the LHRC.

The above information is a summary only. If you want more information about the complaint process, you may address questions to the Human Rights Advocate or obtain more information from any GYG staff member. Additionally, you are entitled to a complete copy of The Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers of Mental Health, Mental Retardation, and Substance Abuse Services. These rules and regulations describe the complaint process in detail. If you want a copy of these rules and regulations, GYG must supply them to you.

By my signature below, I acknowledge receipt and understanding of the Human Rights Complaint Process.

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Program Rules

During the provision of Guiding Young Girls (GYG) services, client(s) shall:

1. Participate fully and honestly in treatment and services activities;

2. Remain available for appointments with their GYG counselor(s) and mentor(s);

3. Refrain from the use of any abusive vulgar, obscene or demeaning language;

4. Refrain from any harassing, aggressive, threatening or assaultive conduct towards others; and

5. Respect the property right of others.

A GYG staff member has explained the foregoing rules to me, and I have read and understand them. I understand that, if a client engages in repeated or serious violations of these rules, the client may be discharged from the GYG Program.

Signatures(s):

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Authorization to Transport

I, _______________________, the client or parent/legal guardian of_________________, do hereby authorize the assigned staff member (s) of GYG Mental Health Agency the right to transport my child and/or children.

This authorization is in effect for the time that services are provided by Guiding Young Girls.

When under our supervision, GYG staff will exercise our best judgment and observe normal precautions. Nevertheless, unforeseeable situations may arise that would require your child to be treated medically on an emergency basis. In such a case, we will make every possible attempt to reach you before making any decisions. However, in the event that we are unable to reach you, we are asking for your permission to seek medical care on behalf of the above named child.

I agree to release GYG from liability resulting from an incident or when providing emergency medical treatment becomes necessary for the welfare of the above named child.

Signatures(s):

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

GYG MENTAL HEALTH AGENCY

Treatment and Discharge Participation

All GYG clients shall be expected to participate in all Individualized Treatment Planning as well as the Discharge Planning of the client. Client and family participation shall begin with the development of the ISP and be finalized through the recommendation and utilization of the GYG treatment review team, the client and family progress, recommendation of the primary worker and the referring agent. The Clinical Director must approve all unplanned discharges.

All clients and parents shall participate in the development of their Individualized Treatment Plan (ITP). This plan shall be developed within 30 days after the initial Prior Authorization (PA) start date.

All clients shall receive a pre-discharge staffing to ensure:

1. Appropriate placement.

2. Identification of community resources that can provide adequate support to the client and their family.

GYG shall provide Pre-Discharge Staffing on the 90th and 180th days to ensure appropriate discharge planning for all clients. All GYG discharge planning and discharge shall be consistent with the client’s individualized services plan and the criteria for discharge. The client, parents/custodian (if applicable), supervisor and clinical director shall participate in these staffings.

The client’s, their parent/guardian, and legally authorized representative’s involvement in the ITP and discharge planning is mandatory and shall be documented in the client’s service record. GYG shall provide every client, parent/guardian and/or their legally authorized representative with ITP as well as discharge instructions in writing.

Signatures(s):

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

GYG Mental Health Agency

Client & Family Receipt of Information

Orientation Form

Client Name: Client ID:

GYG shall inform all clients and their families, guardians, and/or legally authorized representative of their client rights and level of program services provided by GYG.

1. Each GYG client shall receive services according to the law and sound therapeutic practices.

2. GYG shall document that orientation has been provided to clients, parents and/or the legal guardian/legally authorized representative.

3. If the client, parents and/or the legal guardian/legally authorized representative refuse to sign the client orientation document, it will be documented on the form and placed in the clients service file.

I have read or had said material explained to me and received the GYG Client Orientation Informational Package, which was presented to parent/guardian and my legally authorized representative and/or myself.

I, (client or parent/guardian) am acknowledging the fact that I have received said materials and/or been orientated by initialing in front of each item that was received and/or that I have signed.

__________ GYG – Emergency Medical Form

__________ GYG – Consent for Assessment Process;

__________ GYG - Agency Information & Hours of Operation; (Give Family a Copy)

__________ GYG - Mission Statement;

__________ GYG – Health Information Protection and Privacy Act (HIPPA) (Give Family a Copy);

__________ GYG – Notice of Privacy Practice (Give Family a Copy);

__________ GYG - Notice of Client’s Rights;

__________ GYG – Assurance of Clients Rights;

__________ GYG – Medicaid Appeal Process;

__________ GYG – Area Medicaid Provider Receipt;

__________ GYG – How to File a human Rights Complaint;

__________ GYG – Program Rules;

__________ GYG – Transportation Authorization for Clients;

__________ GYG – Treatment and Discharge Planning Participation;

__________ GYG – Release of Information Form;

I understand that as a Medicaid recipient I have a choice of providers. You can identify other providers at http HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP":// HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"www HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP". HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"dmas HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP". HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"virginia HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP". HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"gov HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"/ HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"provider HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"_ HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"search HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP". HYPERLINK "http://www.dmas.virginia.gov/provider_search.ASP"ASP

Signatures(s):

Client’s Signature: ______________________________________________________________

Parent/Guardian (if applicable):____________________________________________________

GYG Staff Signature: ____________________________________________________________

Date: ________________________

Preliminary Service Plan

Client Name: ________________________ Client # _______________________

Start Date: _________________ GYG Assessor: _______________________

Preliminary Treatment Plan is effective for 30days following the Start Date

Needs Assessment: (check all that apply)

___Assistance with initiating/maintaining social relationships

___Assistance with medication compliance

___Assistance with scheduling/maintaining medical appointments

___Financial/budgeting assistance

___Residential/housing assistance

___Vocational assistance

___Transportation assistance

___Assistance with developing leisure activities

___Assistance with school problems

___Assistance with cultural assimilation

___Assistance with other physical health needs

___Assistance with reducing family conflict

___Assistance with parenting skills

___Assistance to reduce/eliminate unproductive behaviors

___Assistance to maintain abstinence from substance use

___Assistance to maintain safety in the home

___Assistance to maintain activities of daily living

___Other (Please Explain):_____________________________________________________________________________

Initial Service Plan Goals (check all that apply):

Client will:

___Refrain from all illegal activities including substance use

___Obtain a psychological evaluation

___Obtain a psychiatric/ medication evaluation

___Comply with medication regimen as prescribed

___Comply with household rules

___Comply with rules of probation/parole

___Improve communication skills with others

___Attend school daily and arrive on time

___Comply with rules/expectations of the school

___Stabilize mood and behavior in order to remain in the home

___Access community resources to facilitate self-sufficiency and overall well-being

___Demonstrate age-appropriate social skills

___Demonstrate an ability to maintain health and safety

Client’s Signature: Date:

Parent/Guardian (if applicable): Date:

GYG Staff Signature: Date:

GYG LMHP Signature: Date:

Suicide/Homicide Safety Plan

These are the steps to take if my suicidal/homicidal thoughts return, continue, or become stronger:

1. Create a safe environment, removing all sharp objects (e.g., pens, pencils, mirrors, hard plastic items, utensils etc.) and firearms

2. Identify support systems:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

3. If you are concerned about your safety CALL 911 immediately.

a. National Suicide Prevention Lifeline: 1-800-273 (TALK) 8255 or 1-800-SUICIDE (784-2433)

b. My local Community Services Board:

i. Hampton-Newport News: 757-788-0011

ii. Norfolk: 757-664-7690

iii. Portsmouth Behavioral Health: 757-393-8990 or 757-391-3167

iv. Chesapeake: 757-547-9334 or 548-7000 (after 6 pm)

v. Virginia Beach: 757-385-0888

vi. Western Tidewater: 757-925-2484

vii. Colonial Behavioral Health: 757-220-3200

viii. Middle Peninsula/Northern Neck: 804-693-5057

c. My counselor’s name & number is: ______________________________

d. My trusted friend or family name & number is: ___________________________

e. My trusted friend or family name & number is: ___________________________

f. My trusted friend or family name & number is: ___________________________

I, , understand the above Safety Plan is to assist me if I begin to have suicidal and/or homicidal thoughts or if my suicidal and/or homicidal thoughts increase. The above Safety Plan includes the steps that I will take to keep me safe and get me the support I need.

Client’s signature:

_______________________________________________________________

Parent/Guardian signature (if applicable): ________________________________________________

GYG staff signature: _________________________________________________________________

Supervisor signature (LMHP or LMHP-E): ________________________________________________

GYG Client Information Packet

Agency Information & Hours of Operation

(Give Copy to Client and Family)

GYG Mental Health Agency is a community-based mental health agency licensed to operate in the Commonwealth of Virginia. GYG is a strength based, community base service provider, that will adhere to all Virginia Department of Behavioral Health and Developmental Services regulations and maintain secure, confidential documentation on each client.

Our Mission Statement:

GYG Mental Health Agency believes that every child and their family deserves the right remain intact. It is also our belief that every family has the right when receiving services to be treated with dignity and respect. Therefore, as an agency we are dedicated to providing a service that is individualized, therapeutically appropriate with the highest levels of accountability and quality, which shall be offered to all children and families without exception. GYG Mental Health Agency shall also be dedicated to teaching families the needed skills to assist as well as ensure family preservation and assist in the reunification of children and families.

GYG services provided shall include, but are not limited to the following: crisis treatment, individual and family counseling, communication skills for appropriate problem-solving, anger management, interpersonal interaction, case management activities, educational assistance, out – patient clinical services as well as coordination with other involved services, and 24-hour emergency response .

GYG is located at 809 Main Street Suite 100 Newport News, Virginia 23605; our office number is 757.595.8008, our fax number is 757.595.8002 and our website address is www HYPERLINK "http://www.guidingyounggirls.com". HYPERLINK "http://www.guidingyounggirls.com"guidingyounggirls HYPERLINK "http://www.guidingyounggirls.com". HYPERLINK "http://www.guidingyounggirls.com"com . GYG’s office hours are 9am to 5pm, Monday thru Friday; GYG’s after hour emergency number is 757.240.9359.

All counselors shall meet the DMAS employment eligibility requirements as either an Quality Mental Health Professional (QMHP), Licensed Mental Health Professional (LMHP) and/or be licensed eligible.

We thank you for the opportunity to service your child and family and sincerely believe that we can bring about change, instill hope and change the world through “using a holistic family approach to change the world one family at a time.”

HIPPA Policy

(Give to Client and Family – Copy)

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Why We Have This Privacy Notice

We are required by law to maintain the privacy of protected health information, and to provide you with notice of our legal duties and our privacy practices with respect to this protected health information. Also, we must abide by the terms of this Notice. If we make any changes in the Notice, we must notify you before the change can take effect. We reserve the right to change the terms of this Notice and to make any new Notice provisions effective for all protected health information that we maintain. You will be asked to acknowledge that you have received this Notice, and you have a right to have a hard copy of this Notice.

In order to effectively provide services to individuals GYG Mental Health Agency must utilize and in some cases disclose information about individuals receiving services. We must do that in order to provide services. This Notice explains how we may use and disclose information about you. It also describes your rights to see, amend, and control your “protected health information”(PHI), which is defined as “information related to your past, present or future physical or mental health or condition and related health care services, including demographic information that may identify you..” This Notice is about the use and disclosure of your “PHI”. Sometimes the word” information” or the word “record(s)” or the phrase “medical record(s)” will be used. When they appear in this Notice, they mean the same thing as “PHI”. The word “individual”, when used in this notice, refers to you and other clients of GYG Mental Health Agency. If you have any questions about this Notice, or about any of GYG Mental Health Agency privacy policies, procedures or practices, please call us at (757-595-8008), and ask to speak with our Privacy Officer.

Permitted Uses and Disclosures of Protected Health Information without the Written Authorization of the Individual: Treatment, Payment and Health Care Operations. Medical privacy laws try to make sure that the protection of your privacy does not interfere with your ability to get treatment. Therefore, the law allows us to use and disclose your protected health information, without asking for your prior authorization, for the following purposes:

For treatment purposes: Your protected health information may be shared among staff and consultants of the GYG Mental Health Agency as part of the treatment process.

EXAMPLE: A therapist may speak to their supervisor about the need for medication. During those consultations, health information about you will be shared. Your protected health information may be shared with another treatment provider who is treating you. EXAMPLE: if you had to go to the hospital and your treating physician there asked GYG Mental Health Agency staff about medications you are taking, that information could be shared with your treating physician to help that physician give you better care.

For payment purposes: In order to get paid for providing treatment to you, GYG Mental Health Agency must send some treatment information about you to the company (such as your health insurance company) that is responsible for paying for that treatment. Such companies have a right to review treatment information about you to make sure that the treatment meets their standards for payment. Therefore, we may use information about you to arrange for payment (for example, preparing bills and managing accounts), and we may disclose information to others (such as insurers, collection agencies and consumer reporting agencies) to get payment. GYG Mental Health Agency will provide only the “minimum necessary information” required by such companies for us to get paid.

EXAMPLE: The Department of Medical Assistance Services (which administers Medicaid) pay for treatment provided to some clients of GYG Mental Health Agency. DMAS has the authority to review the treatment records of clients to make sure that treatment meets their standards.

For Health Care Operations: There are a numerous ways in which your protected health information must be used and disclosed by GYG Mental Health Agency staff in order to carry out a variety of program activities that are called “health care operations”. These operations are needed to help us to, for example, review and improve the quality of our services and find more effective and efficient ways to serve you.

EXAMPLES: Our professional staff reviews treatment records to make sure that they are accurate, complete, and organized. This is part of our quality assurance program. In addition, we may review treatment records if necessary in taking disciplinary or other corrective action toward a staff person who has not performed properly. Those records may also be reviewed in grievance hearings about such disciplinary or corrective action.

We conduct medical, financial, and legal audits and reviews of our practices and records to make sure that we are doing our job right. Different staff may be involved in reviewing your record as part of this process. We also cooperate with outside organizations that review treatment records to evaluate, certify or license our staff or our program. In addition to GYG Mental Health Agency staff, the GYG Mental Health Agency may receive help in its health care operations from other persons, such as our attorney. It may also contract with professionals in other organizations to help. These persons and departments are required to keep confidential any protected health information they receive in doing this work. We sometimes provide training programs for students, trainees and others to help them practice or improve their skills.

Other Permitted Uses and Disclosures of Protected Health Information Without Written Authorization of the Individual.

Required by law: We may use and disclose information about you whenever we are required by law to do so. There are many federal and state laws that require us to use and disclose information about individuals receiving services from us. We will comply with those requirements, and will limit the information we provide to what is required by law.

EXAMPLES: Virginia law requires us to report to certain persons or agencies if an individual who is receiving services threatens to harm another individual. We are required by Virginia law to report to the local department of social services information that we have that leads us to suspect that a child has been abused or neglected.

We are licensed by the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS). And they require GYG Mental Health Agency to release your PHI to the DMHMRSAS, but also require the DMHMRSAS to implement procedures to protect the confidentiality of this information.

Public Health authorities: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. These disclosures normally are made for such purposes as preventing, controlling or investigating diseases and injuries to persons, and monitoring drugs or devices regulated by the Food and Drug Administration (FDA)

EXAMPLES: We may also be required to report information that you have been exposed to a communicable disease. For the purpose of preventing or controlling disease, injury or disability we are required to report certain information to the Health Department. This includes vital events such as death.

Health oversight activities: Virginia statutes have set up a number of agencies and offices that monitor treatment providers like GYG Mental Health Agency to make sure that they are providing proper care and are complying with the law. These and other agencies may also monitor insurance companies and others who may pay for our services. These agencies and offices have the authority to review treatment records of individuals as part of their oversight of providers.

EXAMPLES: The Virginia Office of Protection and Advocacy (VOPA) was created by the Virginia General Assembly as an independent body that monitors the treatment of persons with disabilities in different settings, including treatment settings. They have the right to review the records of individuals receiving treatment services as part of their job to ensure that these individuals are being treated right.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal, to the extent that the order requires us. We may also respond to subpoenas, discovery requests or other lawful process, but in those cases the persons seeking the information must meet certain legal requirements to protect the records. Our normal practice is to contact you whenever we receive a subpoena or order to disclose your records.

Law Enforcement: We may disclose information about you to a law enforcement official for certain specific law enforcement purposes.

EXAMPLE: We may disclose information about you to a police officer if the officer needs the information to help find or identify a missing person or to catch a criminal suspect.

serious threats to health or safety: We may disclose information about you if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, but only to persons who may be able to prevent or lessen the threat.

Coroners, Funeral Directors, and Organ Donation: We may disclose information about you to a coroner, medical examiner, or funeral director, or to organizations that help with organ, eye and tissue transplants.

Research: We may disclose information about you to researchers when their research has been approved by an institutional review board that has approved the research and has required the researchers to protect the privacy of your information.

Military activity and National security: Under certain conditions, we may disclose information to military authorities about individuals receiving services from us who are in the military. We may also disclose information to authorized federal officials for national security and intelligence activities.

Inmates: If you are an inmate in a correctional or detention facility, we may disclose information about you to that facility for certain treatment and safety purposes.

Workers’ Compensation: We may disclose information about you in order to comply with workers’ compensation laws.

Secretary of Health and Human Services: We must disclose information as required by the Secretary of U.S. Department of Health and Human Services for purposes of making sure that we are complying with the Privacy Rule developed under the Health Insurance Portability and accountability Act (HIPAA).

Enhancing Your Healthcare: Some of our programs use and disclose your information in order to provide the following support to enhance your overall health care:

· Appointment reminders by call or letter

· Providing information about health-related benefits and services that may be of interest to you

Uses and Disclosures of Protected Health Information in Which You Have an Opportunity to Agree or Object

Involvement by Others in Individual’s Care: We may disclose information to a family member, other relative, close personal friend or other person you identify, IF that information is directly related to such person’s involvement in your treatment or payment for your treatment.

EXAMPLE: You ask that your sister be present at a meeting with your treating clinician. We may also let them know where you are or if something has happened to you. Usually, this will be done only if you are present and do not object. In some situations (for example, picking up a prescription for you), this disclosure may be made without your being present. You may ask us at any time not to disclose information about you to persons involved in your care.

We will follow your request, except in limited circumstances (such as emergencies). Our usual practice is to get your written authorization to disclose information to others.

Disaster Relief: We may use or disclose information about you to an agency providing disaster relief in cases where their help is needed. We will try to get your permission before doing this.

Other Uses and Disclosures of Your Information: Written Authorization Required

Other uses and disclosures of information not covered by this Notice or the laws that apply to GYG will be made only with your written authorization. If you authorize us to use or disclose information about you, you may revoke that authorization at any time. That authorization must be in writing and must be given to your treating counselor, or the Privacy officer, before it becomes effective. If you revoke your authorization, we will stop using or disclosing the information that was covered in your authorization (unless we have independent legal authority to use or disclose it). When you revoke an authorization to disclose information, we cannot take back any disclosures we have already made with your authorization.

· Your Rights to Your Protected Health Information There are several rights concerning your health information in the medical record that we want you to be aware of:

· You have the right to request access to your medical record in order to inspect it or make copies. However this right is not absolute. You cannot access information compiled in reasonable anticipation of or for use in a civil, criminal or administrative action or proceeding. Due to federal regulations access to certain information under the Clinical Lab Improvements Amendments is prohibited. We can deny you access to your medical record in certain limited situations, such as if your treating physician has made a written determination in your record that providing you access to your medical record would endanger your life or physical safety. You have the right to request review of such denial, and to have your lawyer or another physician receive the record. Within 15 calendar days after the receipt of your written request for access, we will provide you with access to your record. The charge for making any copies you desire is $.50per page and staff time if it takes more than 15 minutes to retrieve and copy the information requested. Your request to review, inspect, copy or amend your record will be kept confidential. For more information, please contact the GYG Mental Health Agency Privacy Officer, whose name, address and phone numbers are listed below.

· You have the right to request an amendment to your medical record. If you believe that GYG has information about you that is inaccurate or incomplete, you have the right to request we amend that information and notify others about it. Your request must be in writing, and should include exactly what amendment you are requesting and the reason which supports an amendment. Within 60 days after the receipt of your request we will either notify you that the amendment has been accepted and ask you to identify the relevant persons to be notified, or we will provide you with a letter indicating that your request has been denied. If your request to amend your record was denied you will receive a letter with the following: 1) an explanation of why your request was denied, 2) instructions on how to submit a written statement disagreeing with the denial, and 3) information about the person(s) with whom you may lodge a complaint about the denial. You can ask that your request for amendment and its denial be included with any past and/or future disclosures of the portions of the record that are the subject of the amendment request. You may contact your counselor GYG Mental Health Agency Privacy Officer (whose name, address and phone number are listed below) about amending your record.

· You have the right to receive an accounting of certain of the GYG Mental Health Agency disclosures of your medical record. GYG Mental Health Agency is required by the Human Rights regulations and by the HIPAA Privacy Rule to make and maintain a written accounting of certain disclosures of your protected health information. Upon written request, you have a right to receive that written accounting of those disclosures. Under HIPAA, we must keep an accounting of information released during the prior six years, but are not required to account for releases made prior to April 14, 2003. You must submit your request for an accounting to your counselor or GYG Mental Health Agency Privacy Office (whose name, address and phone number are listed below). The request must state the time period that you want the accounting to cover.

· You have the right to ask for a restriction with regard to the use or disclosure of your medical record. You have the right to request that we limit the use and disclosure of protected health information about you for treatment, payment and health care operations. We are NOT required to agree to your request. If we do agree to your request, we will follow your restrictions (except where the information is needed for emergency treatment). You can cancel the restrictions at any time. We can cancel the restrictions at any time, as long as we notify you of the cancellation, and apply the restrictions to information that was collected before the cancellation.

· You have the right to request an alternative method of being contacted. Normally, GYG Mental Health Agency staff will send letters, bills, updates, or other information to you at your home, and may call you at home to schedule or remind you of appointments or to obtain needed information from you. You have the right to request that we communicate with you about treatment matters in a certain way or at a certain location. For example, you can ask that we contact you at work, or only by mail.

· You have the right to a paper copy of this Notice. You have the right to receive a paper copy of this notice at any time, even if you agreed to receive this notice electronically. You can get an electronic copy of this Notice at our website, www.guidingyounggirls.com. To obtain a paper copy of this Notice, talk with or write to your counselor or the GYG Mental Health Agency Privacy Officer (whose name, address and phone number are listed below).

· You have a right to file a complaint or ask for additional information about our privacy policy. If you feel that any of your privacy rights has been violated, or if you would like additional information concerning our privacy policy, or the federal and state laws pertaining to privacy, please contact any of the persons listed below. We will not take action against you or change our treatment of you in any way because you file a complaint. You may contact any of the following persons:

Daniel R. Brown Reginald Daye

GYG Mental Health Agency Regional Human Rights Advocate

809 Main Street Suite 100 Eastern State Hospital Satellite Office

Newport News, Virginia 23605 P.O. Box 8791

757-595-8008 Williamsburg, Virginia 23187-8791

757-253-7061

Secretary of the Department of Health and Human Services

1800 F Street NW

Washington, DC 20405

www . HYPERLINK "http://www.dhhs.gov"dhhs HYPERLINK "http://www.dhhs.gov". HYPERLINK "http://www.dhhs.gov"gov

(NOTE: Complaints to the Secretary of HHS should be made no later than 180 days after the privacy violation occurred or you became aware (or reasonably should have been aware) that the privacy violation had occurred. This time limit may be extended for good cause.)

A complaint can be made in person, over the phone or by mail.

Alcohol and Drug Abuse Information

The privacy of information held by GYG Mental Health Agency which identifies, or could identify, a person as an alcohol or drug abuser, is controlled by a specific federal privacy law. The privacy standards of 42 CFR Part 2 (authorized by 42 U.S.C. 290dd-3and 42 U.S.C. 290ee-3) are often more restrictive than the standards set out in this Notice, and we must follow the more restrictive standards. Generally, GYG Mental Health Agency may not say to a person outside the program that you attend the program, or disclose any information identifying you as an alcohol or drug abuser unless: (1) you authorize it in writing; (2) the disclosure is allowed by a court order; or (3) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Violation of Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by an individual or against any person who works for GYG Mental Health Agency or about any threat to commit such a crime. They also do not protect against any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

Minors

Under Virginia law, minors are deemed to be adults for purposes of giving consent to outpatient treatment for mental health services. Under federal law (42 CFR Part 2), a minor who becomes a patient for substance abuse treatment has the same authority as any adult patient in regard to the privacy of his or her treatment records. The minor’s parents, guardian, or legal custodian can have access to treatment records only with the minor’s permission. However, in the case of a minor who is receiving outpatient mental health services, the minor’s parents, guardian, or other legal custodian also have a right of access to the minor’s records. There are certain narrow exceptions in which a parent, guardian, or other legal custodian can be denied access to a minor’s records.

Personal representative

When an individual is incapacitated or otherwise unable to give informed consent to treatment or authorization for the disclosure of records, that person’s “personal representative” may exercise the authority of the individual in regard to the privacy of the individual’s records. A “personal representative” is a person authorized under Virginia law to give substitute authorization for the individual, such as a guardian, attorney-in-fact, or, under certain circumstances and procedures, a family member or other person designated as a “legally authorized representative” under Virginia’s Human Rights regulations. However, the individual must be included in decisions about disclosing information, to the extent that the individual is able, and, unless the personal representative is a guardian with specific authority to act, any objection by the individual to a disclosure of records, even if the personal representative approves, must be reviewed before we can disclose the information. Finally, a personal representative’s access to an individual’s information can be denied if a licensed health care professional determines in the individual’s record that such access by the personal representative is reasonably likely to cause substantial harm to the individual or to another person.

Changes to Privacy Practices

GYG Mental Health Agency reserves the right to change any of its privacy policies and related practices at any time, as allowed by federal and state law. You will receive notice of changes in one or more of the following ways: mail; discussion with an agency representative; electronically; a notice prominently posted in a public area, such as the waiting room.

EFFECTIVE DATE: February 11, 2011

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. Guiding Young Girls is committed to protecting this medical information, which may identify you and relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices describes how we may use and disclose your medical information in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your medical information.

GYG is required by law to maintain the privacy of medical information and to provide you with notice of our legal duties and privacy practices with respect to medical information. We are required to abide by the terms of this Notice of Privacy Practices. GYG reserves the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all medical information that we maintain at that time and a revised Notice of Privacy Practices by providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

For Treatment - Your medical information may be used and disclosed by those outside of GYG who are involved in your care for the purpose of providing, coordinating, or managing your mental health care treatment and related services with your authorization. Providing effective quality care also includes consultation with clinical supervisors or other treatment team members.

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

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

Substance Abuse Information . All medical information regarding substance abuse is kept strictly confidential and disclosed only in accordance with federal regulation (42 CFR part 2). The federal rules prohibit disclosure of this information unless expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42 CFR part 2. Disclosure of any medical referencing alcohol or substance abuse may only be made with your written permission.

Required by Law. Under the law, GYG must make disclosures of your medical information to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization.

Abuse and Neglect Judicial and Administrative Proceedings

Emergencies Law Enforcement

National Security Public Safety (Duty to Warn)

Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

· Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or health department)

· Required by Court Order

· Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

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

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

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding your personal medical information maintained by our GYG. To exercise any of these rights, please submit your request in writing to our Privacy Officer, Daniel Brown :

8. Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy medical information that may be used to make decisions about your care. Your right to inspect and copy medical information will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.

9. Right to Amend. If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information, although we are not required to agree to the amendment.

10. Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your medical information. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

11. Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your medical information for treatment, payment, or health care operations. We are not required to agree to your request.

12. Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

13. Right to a Copy of this Notice. You have the right to a copy of this Notice.

14. Electronic Transactions Standards. All electronic transmissions follow GYG established security guidelines necessary to protect your confidentiality.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing through ​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Daniel Brown, our Privacy Officer, at (757-595-8008). If GYG is unable to satisfactorily resolve your concern, you have the right to file a complaint with the Secretary of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling (202) 619-0257. Your clinical care with GYG will not be compromised if a complaint is filed. This notice will be reviewed with you upon initiation of services and will be in effect as of that date.

GYG MENTAL HEALTH AGENCY

Client’s Notice of Service Rights

1. Retain his legal rights as provided by state and federal law.

2. Receive prompt evaluation and treatment or training about which he is informed insofar as he is capable of understanding.

3. Be treated with dignity as a human being and be free from abuse.

4. Not be the subject of experimental or investigational research without his prior written and informed consent or that of the legally authorized representative.

5. Be afforded an opportunity to have access to consultation with a private physician at his own expense, and in the case of hazardous treatment or irreversible surgical procedures have, upon request, an impartial review prior to implementation, except in case of emergency procedures required for the preservation of his health.

6. Be treated under the least restrictive conditions consistent with his condition and not be subjected to unnecessary physical restraint and isolation.

7. Be allowed to send and receive sealed letter mail.

8. Have access to his medical and mental records and be assured of their confidentiality, but notwithstanding other provisions of law, such right shall be limited to access consistent with his condition and sound therapeutic treatment.

9. Have the right to an impartial review of violations of the rights assured under this section and the right to access to legal counsel.

Please note that you are also entitled to a copy of the document entitled “How to File a Human Rights Complaint.”

GYG MENTAL HEALTH AGENCY

Assurance of Client’s Rights

GYG Program consumers/families will be informed at intake and annually of their Human Rights. GYG shall advise all consumers/families of rights and increase probability of respect and dignity for all persons involved in the program.

Every GYG consumer and family, at intake, will sign a policy outlining Human Rights. This policy will be explained by designated program staff and will include the following Bill of Rights:

1. The Consumer has the right to choose a provider of their choice at anytime they are receiving any service.

2. The consumer has the right for recognition, respect and dignity as a human individual regardless of source (s) of financial support.

3. The consumer has the right to use his/her preferred or legal name.

4. The consumer shall retain his/her rights as provided by State and Federal law.

5. The consumer has the right to participate in his/her plans for treatment, which shall be explained in terms (in a manner) consumer may understand. The consumer has the right to an individual service plan with periodic review.

6. The consumer has the right to and will be informed of the procedure to access and provide corrections to his/her own service records.

7. The consumer has the right to refuse treatment to the extent permitted by law, and to be informed of the correspondences of this action. The consumer has the right to an adequate number of competent, qualified, and experienced staff supervising and implementing the service plan.

8. The consumer has the right to continuity of care, including appropriate follow-up care, planned and initiated by the time of discharge.

9. The consumer has the right to be informed of the use of one-way mirrors, tape recorders, audio-visual or data processing equipment which may be used in a therapeutic process prior to it’s use. No information gained by the above shall be disclosed at any time (current or future) without prior written consent of the consumer except as required by law.

10. The consumer has the right to confidentiality.

11. The consumer has a right to a safe environment.

12. The consumer has the right not to be the subject of experimental or investigative research.

13. The consumer has the right to be treated under the least restrictive conditions consistent with his/her condition and not be subjected to physical restraint and seclusion.

14. The consumer has the right to have access to his/her records and be assured of their confidentiality but, not withstanding other provisions of law, such right shall be limited to access consistent with his/her condition and sound therapeutic treatment. Access to records may be restricted in those cases where the program believes such access to be contraindicated based on the consumer’s emotional functioning. The rationale for limiting access is clearly documented in the consumer’s record.

15. The consumer has the right to provide corrections to his/her record.

16. He consumer has the right to be informed of the cost of services rendered.

17. The consumer has the right to be informed of the counseling staff responsible for his/her care, and those staff member’s professional status and staff relationship.

18. The consumer has the right to be informed of the source of the program’s reimbursement and any limitations placed on duration of services.

19. The consumer has the right to be informed of any change and the reasons for such change in the staff responsibilities for the individual, or any transfer of the individual within or outside the program.

20. The consumer has the right to be informed of the rules and regulations of the program applicable to his/her conduct and to be informed of his/her rights within the program that can be easily understood.

21. The consumer has the right to informed consent, written, dated and signed to the following:

e. Voluntary admission to the program;

f. The release of confidential information;

g. The use of audio-visual equipment;

h. Discharge plans;

22. The consumer has the right not to work or provide services for the agency.

23. If the consumer feels that his/her rights have been abridged or violated, then he/she may notify the Family Redirection Institute, Inc. Advocate either verbally or in writing. It is the responsibility of the Advocate to handle the matter in a therapeutic fashion.

24. You may file a complaint with any program supervisor if your believe any of your rights under the Community Regulations has been violated. You have the right to meet with the program supervisor investigating the complaint, and you may appeal the decision of the program director to the Local Human Rights committee (LHRC).

Regional Advocate: GYG Mental Health Agency Advocate is:

Reginald T. Daye Daniel R. Brown

Eastern State Hospital 809 Main Street Suite 100

Bldg. 33 Room 147, Drawer A Newport News, Virginia 23605

Williamsburg, VA 23187 Phone: (757) 595-8008

Phone: (804) 253-5461

(804) 786-3988

GYG MENTAL HEALTH AGENCY

How to File a Human Rights Complaint Client Form

(Give to Client & Family - Copy)

TERMS YOU SHOULD KNOW:

Complaint - An allegation, made by or on behalf of a client, that there has been a violation of The Rules and Regulations to Assure the Rights of Individuals Receiving Services from Providers of Mental Health, Mental Retardation, and Substance Abuse Services.

Human Rights Advocate- A person employed by the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) to help clients exercise their rights, including their rights to file a complaint.

Local Human Rights Committee (LHRC) - A committee of at least five persons that among other duties, hold hearings regarding clients’ complaints. At least a third of the membership includes individuals who are receiving mental health, mental retardation, or substance abuse services or have received such services within the five years preceding their appointment and family members of such individuals. Other members are professionals in the fields of mental health, mental retardation, or substance abuse services. No member may be an employee of DMHMRSAS or a GYG Employee.

State Human Rights Committee (SHRC) - A committee of a least nine persons that, among other duties, decides appeals from the decisions of the LHRC. Its membership also includes individuals who are receiving mental health, mental retardation, or substance abuse services or have received such services with the five years preceding their appointment.

HOW YOU CAN CONTACT THE HUMAN RIGHTS ADVOCATE OR THE AGENCY DIRECTOR

The Regional Humans Rights Advocates is Reginald Daye. You may contact him by calling (757) 253-7061. The Local Human Rights Advocate is Daniel Brown. You may contact him by calling (757) 595.8008.

INFORMAL COMPLAINT PROCESS

A client or person acting on his behalf may seek an informal resolution of a complaint. However, the client may choose, instead, to pursue the formal complaint resolution process without first pursuing the informal one. The steps are:

1. Report the alleged violation to the Local Human Rights Advocate Daniel R. Brown (757) 595.8008.

2. The Local Human Rights Advocate attempts to resolve the complaint immediately;

3. The Local Human Rights Advocate refers any complaint that is not resolved within five days to the Director of GYG and the Human Rights Advocate; and

4. The client or person acting on his behalf may, at any time, pursue a formal complaint.

FORMAL COMPLAINT PROCESS

The steps of this process are:

1. The client or person acting on his behalf reports the complaint to GYG’s Local Human Rights Advocate or Human Rights Advocate, or both;

2. The Local Human Rights Advocate attempts to resolve the complaint by meeting within twenty four hours with the client, any representative the client chooses, The Human Rights Advocate, and any other persons , as needed, and by conducting an investigation, if necessary;

3. The Local Human Rights Advocate gives the client and his representative a written decision and action plan within ten working days of receiving the complaint;

4. If the client is not satisfied, the client responds in writing to the Local Human Rights Advocate within five working days.

5. The Local Human Rights Advocate my investigate further;

6. The Local Human Rights Advocate gives a final, written decision and action plan to the client, or chosen representative, and the Human Rights Advocate within ten working days of receiving client’s written response.

7. The client, within ten working days of the Local Human Rights Advocate ‘s final decision and with the help of the Human Rights Advocate or any other individual, may file a written petition to the LHRC requesting a hearing;

8. The LHRC holds a hearing within fifteen working days of receiving the petition;

9. The client and the Director of GYG may present witnesses and other evidence;

10. The LHRC, within ten working days of the hearing, makes written finding and recommendations;

11. Within five working days of the LHRC findings, the Director of GYG prepares a written

action plan in response of the LHRC findings;

12. If no one, including the client, his chosen representative, The Human Rights Advocate, or the LHRC, objects to the Director’s action plan, it is implemented;

13. If anyone objects and the Director of GYG does not resolve the objection, the client may appeal to the State Human Rights Committee.

SPECIAL PROCEDURES FOR EMERGENCY LHRC HEARINGS

The steps of this process are:

1. If the Human Rights Advocate finds that there is a substantial risk that serious and irreparable harm will result if a complaint is not resolved immediately, the LHRC holds a preliminary hearing within seventy-two hours;

2. At the end of the hearing, the LHRC makes preliminary findings and recommendations;

3. The Director prepares and carries out and action plan within twenty-four hours;

4. If the client or Human Rights Advocate objects to the action plan, the LHRC holds a full hearing within five working days of the objection.

OTHER VARIATIONS OF THE COMPLAINT PROCESS

The above-described process may vary in cases where it is alleged that a client has been abused, exploited, or neglected, cases where discrimination is alleged, and in some cases involving consent to treatment, human research, or disclosure of information. However, in each of these types of cases, the client is entitled to request a decision from the LHRC.

The above information is a summary only. If you want more information about the complaint process, you may address questions to the Human Rights Advocate or obtain more information from any GYG staff member. Additionally, you are entitled to a complete copy of The Rules and Regulations to Assure the Rights of Individuals Receiving Services from the Providers of Mental Health, Mental Retardation and Substance Abuse Services. These rules and regulations describe the complaint process in detail. If you want a copy of these rules and regulations, GYG must supply them to you.