By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.
Intake involves a lot of paperwork.
Getting a client signed up for a drug treatment program involves a lot of paperwork that needs to be completed before the counseling can begin. Drug counselors need to know how to do this function, although the exact paperwork they will have to do can vary a great deal from program to program. Many treatment agencies now use computerized systems. As the counseling field shifts towards more electronic records, more of the intake paperwork will end up on the computer. Some systems now include electronic signature pads that will capture the client signature onto the electronic file.
Some of this paperwork part can be done by office staff. Larger drug treatment programs may have one person assigned to do the intake paperwork. There are some advantages to having the primary counselor, the one the client will see the client throughout treatment, do the intake. When the client first comes into drug treatment, they are likely to be anxious and uncertain. Developing a relationship, establishing rapport, is an essential part of what staff at a drug treatment program must do. It’s easier to build up a rapport when the client sees the same person throughout treatment.
Informed consent is a required part of treatment.
Informed consent is not a separate specific drug counselor function, but it should be incorporated into all the intake paperwork as part of the legal and ethical responsibilities of a counselor. Fees need to be discussed during the first session the staff spends with the client.
Limits of confidentiality and the exceptions to them need to be explained to the client. What information will the program keep confidential and what information might be disclosed. Drug counseling has an extremely high requirement for confidentiality. Drug counselors should not even confirm or deny that someone is in their program.
Drug counselors are mandated reporters who must report clients who are a danger to themselves or others. They also are required to report abuse of the child, an elderly, or a disabled person. In some jurisdictions, they may be required to report clients who view child pornography. All these exceptions to confidentiality need to be explained to the client during the intake process.
Because so many clients are referred to drug treatment by the criminal justice system, parole probation, or the courts, more of the client’s information may be divulged than might happen in mental health counseling.
As part of the evidence that you did informed consent, the client will be required to sign a form called either a consent for treatment or a treatment agreement.
Consent to release information forms.
If any information about a client will be released to an outside party, a specific form called a consent for release of information should be filled out and signed by the client. These forms are often referred to by counselors as “releases.” Most releases can be revoked by the client, which must be done in writing if they decide they want the drug program stop releasing information. One exception to this right to revoke consent to release information is the “criminal justice consent form.”
If the criminal justice system has sent a client to your program, they will require information about that client. If the client does not wish to sign a release of information, you will not be able to admit that client to your program. Clients who attend a drug treatment program without signing a release for the criminal justice system will not have met their legal requirements for a court-mandated program.
Financial forms are part of drug counseling intakes.
For most programs, someone is paying for treatment. If it’s insurance, then there will be insurance forms to fill out. If the treatment is paid for by the criminal justice system or the child protective services, there will be other forms they will need to fill out. Clients who self-pay will still need to fill out a financial agreement. Some programs have a sliding scale fee agreement for low-income clients. Providing financial information and filling out additional forms may be a part of qualifying for these reduced fees.
HIPPA notice of privacy practices.
Almost all programs nowadays are “covered entities” and must follow the HIPPA regulations. The counselor needs to give the client a notice of privacy practices and have the client sign a form saying they received this information.
Clients need to provide the program with their demographic information. You need to know who it is you’re working with. It’s good practice to have an address and phone number for this client. This form might also next of kin.
Consent to follow-up.
Some programs do follow-up studies to see how effective their treatment is. Studying the results of treatment may be a condition of receiving funding from grants or contracts with governmental agencies. It’s a good practice to have written permission to follow-up, signed at the time of intake. You should also make sure you know how you are allowed to contact the client. If the phone number they gave you is a work phone, they may not want you calling there for follow-up.
Program rules or expectations.
During the intake, the counselor may give the client rules, a form about client rights and responsibilities and other information about the program. Some programs do this after the intake as part of a separate step referred to as the core function of orientation. More about orientation in an upcoming post.
There are a wide variety of other forms used by various treatment programs. Most of these forms have been created by the individual treatment program.
Assessment may take place during intake.
Assessment means different things in different contexts. Assessment is considered a separate drug counselor function and it’s a skill that counselors need to learn and to practice. Assessment may take place during the initial intake. Some programs will schedule a separate appointment for the assessment. Assessment functions as the bridge between the first domain which involves getting clients into treatment, and the second domain which is the work the counselor will do in creating a comprehensive recovery plan.
In our next installment of this “what do drug counselors do and how do they do it” series we will look at the core counselor function of assessment.
For more on the drug counselor domains and the core functions see John W. Herdman’s book Global Criteria; the 12 Core Functions of the Substance Abuse Counselor
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