IL Consent for Intervention and/or Treatment

hereby consent to receive Intervention services and/or Treatment services from Right Direction Services, LLC.

RIGHT DIRECTION SERVICES LLC

7210 E State Street, Suite 102 Rockford IL 61108

I consent to the use or disclosure of my protected health information by Right Direction Services, LLC for the purpose of my care, as well as for obtaining any referrals to a treatment provider.

By signing this Client Information and Consent Form as the Client or Guardian/Parent of said Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form, in the Client Rights document, and rules for participation documents that have been provided to me. I acknowledge that I have been provided with these documents and have been given an appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive Intervention services and/or Treatment from Counselors at Right Direction Services, LLC.

I understand I have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. I understand I have the right to ask questions about any aspects of my care.

am consenting to Right Direction Services, LLC providing me with Intervention Services and/or Treatment.  I have been provided with the Department of Human Services Informed Consent, Brochure, Referral List, Verification form, the agency's Client Rights Document, and the Rules for Participation, and I agree with their terms.

CLIENT INFORMATION SHEET

Consent / Acknowldgements

Participation in the Driving-Under-the-Influence (DUI) Program services through online telehealth Internet technology is entirely voluntary. You are not required to participate in the DUI Program services through this telehealth option.

The telehealth ZOOM tele-conferencing platform selected by Breining Institute complies with the provisions of the Health Insurance Portability and Accountability Act (HIPAA). However, using any online telehealth format may, by its nature, present a potential risk of disclosure of your personal information. If you do not wish to be exposed to this potential risk, you should not use the online telehealth format to complete your DUI program.

By completing this form, you are voluntarily agreeing to receive and participate in DUI Program services using the online telehealth Internet technology.

Consent to Release of Information

You attest to your understanding that Federal and State laws protect the confidentiality of information relating to Right Direction Services LLC (AKA MyDUIClass.com) participants. By signing below and participating in the Right Direction Services LLC (AKA MyDUIClass.com) program activities using the online telehealth technology, you hereby consent to the disclosure of your personal information, and specifically the disclosure of your name and likeness, to the extent necessary for participation in program services provided via telehealth platforms and specifically the Zoom teleconferencing platform.

Confidentiality / Non-Disclosure Agreement - Other Participant Information.

By signing below I attest to my understanding that information relating to Right Direction Services LLC (AKA MyDUIClass.com) program participants is protected from disclosure by Federal and State laws and regulations. I further understand that these laws and regulations prohibit my disclosing to others any information relating to any Right Direction Services LLC (AKA MyDUIClass.com) program participant. By signing below I indicate my agreement that:

1. I will maintain the confidentiality of all information learned and observations made by me during participation in Right Direction Services LLC (AKA MyDUIClass.com) provided via telehealth platforms and specifically information learned and observations made during the Zoom teleconferencing platform.

2. I will not photograph or record the voice or likeness of any other participant while receiving Right Direction Services LLC (AKA MyDUIClass.com) program services provided via telehealth platforms and specifically during any Zoom teleconference.

3. I will maintain the confidentiality of the teleconference by agreeing not to allow any person other than myself to listen to or observe any Right Direction Services LLC (AKA MyDUIClass.com) teleconference providing program services and specifically any Zoom teleconference.

4. I will not allow any other person to photograph or record the voice or likeness of any participant in any Right Direction Services LLC (AKA MyDUIClass.com) teleconference providing program services and specifically any Zoom teleconference.

Client Acknowledgement

By signing and submitting this Agreement:

• I am choosing to voluntarily participate in the DUI Program Services using the online telehealth Internet technology; and
• I understand that there is no assurance of confidentiality when using the online telehealth technology service due to the nature of the Internet technology.

SIGNED FEE SCHEDULE

Zoom DUI Class

Level I - 10 Hours Risk Education     $200

Fee Policy

The fee for the 10 Hours RIsk Education must be paid prior to the start of the class .

Payment Assistance (Illinois Clients Only)

No Illinois resident is ever turned away because of his or her inability to pay. If you are experiencing financial hardship you may be eligible for funding by the Illinois Department of Human Services/Division of Alcoholism and Substance Abuse, provided you are able to support your claim with proof of inability to pay.  Fees can be reviewed at any time there is a change in your financial situation.

Right Direction Services, LLC bills the DDDPF for Indigent Clients

Qualification For Assistance

To qualify for payment assistance thru the DDDPF for Indigent Client Program you will be required to provide the following documentation, which will be maintained in your file:

• Income Verification Documents (pay stub, 1040, W-2, unemployment card)
• Insurance Information (if applicable)
• Employment Information
• Dependent Information

Annual income guidelines to be used to qualify DUI offenders for indigent DUI

These guidelines are the same as the Federal Poverty Guidlines (view)

Persons in Family / Household                              Poverty Guideline

1                                                                             $15,060

2                                                                             $20,440

3                                                                             $25,820

4                                                                             $31,200

5                                                                             $36,580

6                                                                             $41,960

7                                                                             $47,340

8                                                                             $52,720

For families/households with more than 8 persons add $5,380 for each additional person.

CLIENT INCOME INFORMATION

CLIENT INCOME CERTIFICATION

I certify that to the best of my knowledge, and based on the information provided by the client

REFERRAL LIST VERIFICATION FORM & SUPR LIST OF PROVIDERS - WINNEBAGO COUNTY

ROSECRANCE - MARLOWE HOUSE -  RECOVERY HOME
1365 UNIVERSITY DR.
ROCKFORD, IL 61107
815-229-1905 

I have been shown this listing of licensed DUI Risk Education Providers, DUI Evaluation Providers, and Substance Abuse Treatment Programs.  I understand that I may see any necessary services a program of my choice.

Client Rights

You will not be denied access to services on the basis of race, religion, ethnicity, disability, sexual orientation, or HIV status.

You have the right to have services provided in the least restrictive environment available.

You have the right to nondiscriminatory access to services as specified in the American’s With Disabilities Act of 1990 (42 USC 12101).

You have the assurance of confidentiality, which means no information will be released without a signed authorization. Information in client records will be kept confidential according to Federal Law and Regulation, 42 CFR Part 2, the AIDS Confidentiality Act under the Public Heath Communicable Diseases Act 305 and the Health Information Portability and Accountability Act. Information will be provided to other agencies and referral resources only with your written authorization.

You do not have to provide information regarding HIV/AIDS status or testing. If information is provided, it will not appear in your clinical record, be discussed with personnel, or be released to any other agency.

Violations of these laws and regulations are a crime. Suspected violations may be reported to the appropriate authorities. EXCEPTIONS: a) disclosure of information about a crime committed by a client at the organization, or a threat to commit such crime; b) disclosure of information about suspected child abuse or neglect, as allowed by, required by and consistent with State law; c) disclosure of a client’s own records to the client, or as consented to in writing by the client; d) communications of information between or among personnel having a need for the information in connection with their duties either within the organization or with an entity having direct administrative control over the services; e) disclosure of information to medical personnel if necessary in a medical emergency; f) disclosure of information as authorized by an appropriate court order upon showing goof cause, after appropriate procedure and notice, and with appropriate safeguards against unauthorized disclosure contained in the order as set forth in 42 CFR 2.61-2.67 (1987); g) disclosure of information to qualified personnel for the purpose of conducting scientific research as set forth in 42 CFR 2.52 (1987) (if such disclosure is in compliance with HIPAA regulations, 45 CFR 160, 162, and 164; h) disclosure of information to qualified personnel who are authorized by law or who provide financial assistance for the purpose of conducing audit or evaluation activity.

The state of Illinois requires reporting of tuberculosis. Individuals who have suspected or confirmed TB will be reported to Public Health supplying information related to TB as required by the statute.

You have the right to request your health information be transmitted to other agencies by an alternate method; you have the right to request an accounting of disclosures of your health information.

You have the right to give or withhold informed consent regarding treatment and regarding confidential information about you. You have the right to receive information regarding treatment options and to participate in an individual treatment plan and evaluation of treatment including the right to obtain a second opinion from a qualified source at your own expense.

You have the right to inspect and copy your clinical records. You have the right to request corrections of errors or incomplete information.

You may refuse treatment or specific treatment procedures at any time. If treatment is refused, the clinician will discuss alternatives available or the possible consequences of refusing treatment or specific treatment procedures.

You will receive a copy of the Grievance Procedure and will not be denied service, suspended from treatment or terminated from treatment because of filing a grievance.

If abuse or neglect of a client with diminished capacity is suspected, the Department of Public Health and/or other appropriate agencies must be notified.

Any incidents of abuse or neglect will be reported to the Illinois Department of Public Health, Illinois Department of Human Services, or the Illinois State Police for investigation.

You have the right to expect that individuals assigned to your services will have the appropriate education and credentialing and that those individuals will conduct themselves in a professional and ethical manner.

I understand confidentiality protections and my rights as a client as stated and hereby consent to substance-related services. I have received a copy of the Client Rights and Grievance Procedure.

Statement of Client's Rights & Responsibilities

As a Client/Participant of this program, I agree and fully understand that:

I voluntarily seek participation in the DUI Risk Reduction Education Program.

I may voluntarily terminate my participation at any time.

I will make every effort to contribute to group discussions 

I am expected to pay for the classes in full unless I have been approved to receive financial support from ILLINOIS DEPARTMENT OF HUMAN SERVICES, DIVISION OF SUBSTANCE USE PREVENTION & RECOVERY (SUPR)

I am responsible to keep regularly scheduled appointments or to cancel or reschedule more than 24 hours in advance if I am unable to keep an appointment.

I will conduct myself appropriately during classes. I understand that verbal abuse or physical violence threats of physical violence will not be tolerated.

I will not be under the influence of any non-prescribed drug and/or alcohol while attending the DUI Risk Education Program.

Failure to comply with items numbered 5-7, are grounds for termination of services.

I understand that 2 consecutive missed appointments without prior notice or regularly missed appointments are grounds for termination from the program. 

I have the right to be informed in writing, if consideration is being given to ending my program participation. I have the right to contest this termination if I believe it to be unfair.

My personal information and program participation is confidential and can only be released with my written permission.

Documentation of completion of Education will be provided upon achieving a passing score of 75%, all required documentation has been received and all assessed fees have been paid in full.

Client Services Agreement

As a client of Right Direction Services LLC, I agree to and understand that:

I will attend schedule sessions.  Failure to attend will be reported to the Secretary of State.  Three missed sessions for any reason may result in termination from the program.

I will pay assessed fees on time.

I will contribute in establishing and developing my treatment goals.

I will abstain from all mood-altering substances while attending classes.

I will participate in the Risk Reduction Education Program.

I must have a score of 75% or better on the Final Exam to complete this course.

Documentation of completion will be provided after:
a. All documents are filled out and signed
b. Receiving a passing score of 75% or better
c. All fees are paid in full.