ARROWHEAD BEHAVIORAL HEALTH phoenix dui lawyers

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					                           ARROWHEAD BEHAVIORAL HEALTH
                                  9865 W. BELL RD
                                 SUN CITY, AZ 85351

Please visit our website www.abhpsych.com for directions to our office.

Thank you for scheduling your counseling appointment with ABH. It is our goal to provide
you with the highest quality of care. In order to do this, we require information from you that
tells us a little about yourself and the reason you are seeking counseling. The more
information we have initially, the more time we have to spend with you and serve your needs.
If at all possible, please return this packet to our office “PRIOR TO” the day of your first
appointment so we can process your information and establish a clinical chart. Having this
completed and established allows more time in the initial session to get to know you and your
needs. (Bring it with you to the appointment if you did not drop it off).


BEFORE YOUR INITIAL VISIT YOU “MUST” OBTAIN THE FOLLOWING
INFORMATION FROM YOUR INSURANCE CARRIER AND ENCLOSE THIS WITH
YOUR RETURNED PACKET. DO NOT RELY ON WHAT IS PRINTED ON YOUR
CARD, THE CLAIMS ADDRESS IS USUALLY DIFFERENT THAN WHAT IS
WRITTEN, THEREFORE, PHONE CONTACT WILL NEED TO BE MADE TO OBTAIN
THIS INFORMATION. YOU MUST HAVE YOUR INSURANCE CARD WITH YOU AT
TIME OF THE APPOINTMENT.    Thank you.


What company administrates your outpatient “mental health benefits?”

Company Name: _______________________________________________________________

Address where claims are sent: ___________________________________________________

Street: _______________________________________________________________________

City: ___________________________________ State: ______________ ZIP: _____________

Do you have a deductible?       Yes ____ No ____ If so, how much? $ __________________

Your Co-Payment: ____________The number of sessions allowed for the year: __________

Do you require an authorization? If so, you must call for it, and record

It here: #______________________________________________________________________
           PLEASE WRITE CLEARLY SO WE HAVE ALL THE CORRECT INFORMATION
  PATIENT’S NAME (Last, First, Middle Initial)                                          Patients Birth Date   MM/DD/YY
  ARROWHEAD BEHAVIORAL HEALTH
  PATIENT'S ADDRESS (No.. Street)
  9865 W. BELL RD                                                                       6. PATIENT RELATIONSHIP TO INSURED: Self  Spouse  Child  Other 
  SUN CITY, AZ 85351
  CITY                      STATE            ZIP CODE                                   8. PATIENT STATUS
  Thank you for scheduling your counseling                                   Single  Married  Divorced  Widowed  Other 
   TELEPHONE (Include Area Code)
   H: __________________________________________________ 
  appointment with ABH. It is our goal to providehere Employed:
                                                          Contact you                      □ Full-Time       □ Part-Time
  you with the highest quality of care. In Contact to do
   W: __________________________________________________
   Cell:                                                 order you here Student::
                                                         Contact you here                 □ Full-Time      □ Part-Time
   PRIMARY CARE PHYSICIAN
  this, we require information from you that tells us a PHONE:                                          FAX:
                  yourself and the reason you are seeking City,
  little aboutStreet)
   ADDRESS (No.,                                                                                  State             Zip Code
  counseling. The more information we have the
  more time we have to spend with you and serve
   EMERGENCY CONTACT                                                       RELATIONSHIP
  your needs. Therefore, please fill out all the
   REFERRED BY:
  information requested and bring it with you to your AUTHORIZATION NO:
  intake session. We look forward to meeting your
  needs.
    RESPONSIBLE POLICY HOLDER INFORMATION - ALL BOXES “MUST” BE COMPLETED
   ID number or SS#                                                                       Policy Group or FECA No.
   BEFORE YOUR INITIAL VISIT YOU “MUST”
  NAME: (Last, First & FOLLOWING
  OBTAIN THE Middle)                                                     Date of Birth        MM/DD/YY
   INFORMATION FROM YOUR INSURANCE
  ADDRESS (No., Street)                                                  EMPLOYER OR SCHOOL NAME
  CARRIER AND ENCLOSE THIS WITH
   YOUR RETURNED PACKET DO NOTZip Code
  City                             State                  RELY           INSURANCE PLAN NAME OR PROGRAM
  ON WHAT IS PRINTED ON YOUR
  TELEPHONE (include area code)                                                                                                                            YES       NO 
   CARD, THE CLAIMS ADDRESS IS USUALLY IS THERE ANOTHER HEALTH BENEFIT PLAN?
  Home: _______________________________________________ Contact me here (If yes, What Plan?)
  DIFFERENT THAN WHAT IS
  Work: ______________________________________________ Contact me here
   WRITTEN, THEREFORE, PHONE Contact me here
  Cell: ___________________________________CONTACT
  WILL NEED TO BE MADE TO OBTAIN
  THIS INFORMATION.                              PAYMENT, FEES, & CONSENT FOR TREATMENT
If, as a client of Arrowhead Behavioral Health, you are using your insurance benefits, you are obligated to pay any deductible and copay at the time of service. The amount of
deductible and copay is determined by your individual benefit plan. While we can assist you in filing insurance claims, you are responsible for any amounts that your insurance or
health benefit plan does not cover. While we will attempt to verify your benefits it is ultimately your responsibility to know what your health plan will and will not cover. Feel free to
      What company administrates a $25.00 charge on all returned checks. NFS checks must be redeemed with cash, certified check or money order.
discuss insurance coverage with this office. There is your outpatient
Delinquent accounts may be referred for collections and interest may be added to balances over 60 days. I also understand that if I do not show for my appointment or if I cancel
    “mental health benefits?”
my appointment with less than 24 hours notice, I will be charged for that appointment. A client's confidentiality is important and is legally protected. There are however,
circumstances that impose limitations on a client's right or ability to maintain a privileged communication. We are legally bound to report suspected child or elder abuse or neglect,
and are obligated to take steps to inform others if there is a reason to believe that a client is a danger to themselves or others. Confidentiality may also be waived as a result of a
      Company Name:
court order, legal proceeding, referral to a licensing authority, or other statutory requirement. When a clinician is out of town, another professional will cover crisis calls and that
    ____________________________________________ plan is expected to pay for some portion of the cost of services, it must be mutually
professional may be advised of issues that might arise on your case. If a health benefit
understood and accepted that this office may furnish diagnostic, financial, and clinical information to insurance companies, and/or medical review organizations in order to obtain
    ___________________
reimbursement. If you are currently on Short or Long Term disability it must be mutually understood and accepted that this office may furnish diagnostic and clinical information to
your Disability Medical Review Organization if requested either by writing or telephone. Your case may be subject to a Peer Case File Review to insure the highest quality of care.
      Address counseling services are sent:
In the event group where claimsare provided, it is further acknowledged that the therapist or practice cannot be held responsible for a breech of confidentiality on the part
of a peer group member.
  ____________________________________________
I hereby assign insurance of health benefits for treatment for my self, son, daughter, ward, or spouse to Arrowhead Behavioral Health. It is mutually under-e stood, however,
   _______
that I am financially responsible to Arrowhead Behavioral Health for any charges not paid by my insurance company or third party payer.

CLIENT OR PARENT (if client is a minor)__________________________________________________________________________Date:____________________
    Street:
   ____________________________________________
I do hereby seek and consent to take part in treatment at ARROWHEAD BEHAVIORAL HEALTH. I understand that developing a treatment plan with the therapist and
regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have
   ___________________________
been made to me as to the results of treatment or of any procedures provided by the therapist I am aware that I may stop my treatment with the therapist at any time.
The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other
   City: I stop treatment., (For example, If my treatment has been court
problems if ___________________________________ ordered, I will have to answer to the court.) I know that I must call to cancel an appointment
at least 24 hours before the time of the appointment. If I do not cancel or do not show up, I will be charged for that appointment.
  State: ______________ ZIP: _____________
I HAVE REVIEWED THE INFORMATION ON THIS PAGE, AND THE “INFORMATION FOR CLIENTS”, AND ACCEPT THESE UNDERSTANDINGS, AND AGREE TO
HAVE MY SELF, SON, DAUGHTER, WARD, AND/OR SPOUSE PARTICIPATE IN TREATMENT.
  Do you have a deductible? Yes ____ No ____ If
  so, how much? $ __________________
CLIENT OR PARENT (if client is minor):___________________________________________________________________________Date:___________________
  Your Co-Payment: ____________The number of
  sessions allowed for the year: __________
Where were you born? _________________________How long in Phoenix? _________ From Where?_______________________
List all your sisters and brothers & age, from the oldest to youngest, include yourself: _________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Are you parents deceased?  Mother  Father            If decease--- Your age at death: Mother ________ Father __________
***Give a description of your father’s personality and how he treated you: ___________________________________________
___________________________________________________________________________________________________________
****Give a description of your mother’s personality and how she treated you: _________________________________________
___________________________________________________________________________________________________________
If reared by someone other than your natural parents, please identify who they were and describe how they treated you:

___________________________________________________________________________________________________________
Give an impression of your childhood home environment (What kind of relationship existed between the parents, between
parents and children, and between children?_____________________________________________________________________
___________________________________________________________________________________________________________
Which conditions applies to you during childhood? Bedwetting Nail biting Stuttering Sleepwalking
Physical abuse Emotional abuse Sexual abuse PLEASE EXPLAIN: ____________________________________________
___________________________________________________________________________________________________________
Illnesses/Diseases?Accident/Surgeries during childhood: _________________________________________________________
___________________________________________________________________________________________________________
Highest level of education?     Grade School        Jr. High         High School           College       Grad. School
Academic performance in:       Grade School ________ Jr. High ________ High School ___________ College ____________
Your occupation ___________________________ Are up satisfied with it? ________Does it meet your financial needs?______
Are you married? YES NO If married, how long? __________ Have you ever been divorced (number of times) _________
If so, please give dates married and dates of divorce(s). ___________________________________________________________
Please explain causes for divorce(s). ___________________________________________________________________________
Do you have children from either present or past marriages? If so , please indicate present/past, names & ages and whom
they live with now: ___________________________________________________________________________________________
___________________________________________________________________________________________________________


Indicate which of the following behaviors, practices or habits is true for you by marking the boxes:
                    Never    Rarely   Often Very Often                       Never Rarely Often Very Often
Birth-control pills                                   Overeating                              
Use painkillers                                       Take diet pills                         
Use alcohol                                           Takes sedative                          
Marjuana Use                                           Take stimulants                        
Use Cocaine                                            Anger outbursts                        
Use Narcotics                                          Take vacation                          
Gambling                                               Go to concerts                         
Smoke cigarettes                                       Play Sports                            
Chew tobacco                                           Attend sports                          
Drink coffee                                           Exercise                               

                                         ALCOHOL AND SUBSTANCE USE/ABUSE:
   Type           How many drinks/substance per day?      How many per week?         # Years Used     Ages of First Use
_________________________________________________________________________________________________
_________________________________________________________________________________________________


Past hospitalization or treatment for addictions: (If yes, explain) _________________________________________________________
Past Hospitalization for psychological problems(If yes, explain) _________________________________________________________
Have you or any one in your family ever attempted suicide?(explain) _____________________________________________________
Have you ever been arrested, including DUI’s? (Explain) ______________________________________________________________
Is your present sex life satisfactory? Yes No, If no, please explain __________________________________________________
Describe any unpleasant memories about sexual experience(include forced or traumatic sexual incidents):
___________________________________________________________________________________________________________
Describe any sexual inhibitions or problems that you might have at this time. ______________________________________________
Provide information about any unwanted pregnancies and the consequences.______________________________________________
___________________________________________________________________________________________________________
Support Systems: Family                Friends         Church        Self Help Groups   Other __________________________
                                               PLEASE MARK ALL THOSE WHICH APPLY TO YOU

 Depressed Mood.(Sad, Blue, Tearful)                                   Appetite Disturbance               Mood Swings
 Disturbed Sleep (Sleeplessness)                                       Negative Thinking                  Easily fatigued
 Increased need for sleep                                              Difficulty Concentrating            Unexplained Aches &
 Feeling un-rested upon wakening                                       Decreased Energy                                        Pains
 Headaches, Stomachaches, Digestive Problems                           Decreased Motivation               increased irritability
 Feelings of Helplessness, Hopelessness                                Difficulty making decisions        Anger Outbursts
 Excessive Guilt                                                       Increased Withdrawal/Isolating      Irritability
 Decreased Sexual interest                                             Unresolved grief issues            Low frustration tolerance
Previous History of depression: .                                       Loss of pleasure in activities    Low Self-Esteem
               (Treated/Untreated                                       Suicide (Thoughts/Plan/ Attempt

 Excessive anxiety and worry, occurring more days than not for at least 6 months.
 The person finds it difficult to control the worry.
 Restlessness or feeling keyed up or on edge (for at least 6 months).
 Being easily fatigued (for at least 6 months.)
 Difficulty concentrating or mind going blank (for at least 6 months).
 Irritability (for at least 6 months).         Muscle tension (for at least 6 months).
 Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
  (for at least 6 months).
 The anxiety, worry, or physical symptoms cause clinically significant distress or
   impairment in social, occupational, or other important areas of functioning.

ANXIETY/PANIC ATTACKS with: Heart palpitations  Sweats    Shaking    Shortness of breath   Chest Pain    Nausea
Dizzy/Lightheaded  Numb/tingling    Fear of going out HOW FREQUENT ________How long has it been going on ____________

 Makes careless mistakes                                         Talks excessively                 Short Attention Span
 Does not follow through on directions                            Difficulty awaiting turn         Disorganized
Avoids sustained mental attention                                 Many projects at once            Easily Distracted
 Loses things necessary to complete task                          Fidgets                          Blurts out answers
 Often forgetful of daily activities                              Does not seem to listen          Interrupts
 Often leaves seat (even when remaining expected)                 Feeling restless                 Easily bored
 Difficulty with leisure activities quietly                       Often “On the Go”                Procrastinates
 Does not complete projects                                       Impulsive behaviors

 COMPULSIVE BEHAVIORS:              cleaning, checking, hand washing, hoarding,  OBSESSIONS:        Repetitive, Ruminate, Monothematic

STRESSORS: Money Housing Family Conflict                    Work Grief & Loss Illness Transitions Other ______________

How many hours per week do you work? ___________________________
How many hours per day do you spend on the internet?(not including work)? ________________ How many per week? _______________
Who does most of the housecleaning? Wife               Husband             Equally shared responsibility?
Who does most of the cooking?             Wife         Husband             Equally shared responsibility?
What do you do for recreational activities? _________________________________________________________________________________
Do you have any prior history of counseling for mental health, alcohol or drugs, marriage or family, other: (If so. . . dates, provider, type
of interventions, & responses): __________________________________________________________________________________________
______________________________________________________________________________________________________________________
What have been your major crises of the last 1-5 years: ______________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
What has brought you in today, and why now? “BE SPECIFIC/GIVE DETAILS”:______________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
What are your major strengths?: __________________________________________________________________________________________
What spiritual or religious issues are important you? How does your culture influence you?
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
                                                 MEDICAL HISTORY


CLIENT NAME:______________________DATE OF BIRTH:______________TODAY’S DATE:___________


Conditions

Please  or X any of the following illnesses or medical problems you have experienced in the past or currently
experience. If you recall the year the condition started please indicate that also.

   Year     Condition                                               Year    Condition
             Allergies                                                        Hypertension
             Asthma                                                           Hysterectomy
             Bladder Problems                                                 Irritable Bowel Syndrome
             Chronic Fatigue Syndrome                                         Liver Problems
             Chronic Neck and Back Problems                                   Lupus
             Colitis                                                          Migraines
             Congestive Heart Failure                                         Parkinson’s
             Diabetes                                                         Premenstrual Dysphoric Disorder
             Drug Allergies to:                                             Prostrate Problems
             Emphysema                                                        Sexually Transmitted Diseases
             Fibromyalgia                                                     Stroke
             Gerd                                                             Thyroid Disease
             Heart Attack                                                     Other Disorder or Disease Not Listed:
             Hepatitis                                                        
             HIV                                                              


Medications

Please indicate all of the medications and over-the-counter medications you have taken or currently take. It is important
to make the therapist aware of medications taken to avoid drug interactions and optimize the success of your treatment.

Medication       Dosage          Duration       End Date          Side-Effects?                   Effective?
                                             Arrowhead Behavioral Health
                                                   9865 W Bell Rd.
                                                  Sun City, AZ 85351


Cancellation Policy for Counseling Appointments

Our goal is to provide quality care in a timely manner. In order to do so we have implemented an appointment/cancellation policy.
This policy enables us to better utilize our time and your time by sustaining a smooth flow of patients.

Scheduled Appointments

     For a scheduled appointment please call 623-876-1246.

Cancellation of an Appointment

In order to be respectful of the therapeutic needs of Arrowhead’s practice please be courteous and call the practice promptly if you are
unable to attend an appointment. This time will be reallocated to someone who is in need of the therapist’s time.
      Call 24 hours in advance to cancel your scheduled appointment. If you do not reach the receptionist then leave a phone
         message to indicate who you are and the time of the cancelled appointment.
      Call if you are more than ½ hour late to the appointment it will be considered a no show with the $50.00 fee.

Late Cancellations or “No-Shows”

A “No-Show” is someone who misses an appointment without canceling within the prescribed 24 hours prior to the appointment. No-
shows inconvenience those patients who need access to the therapist’s time.

Disability Paperwork

When you made your appointment with Arrowhead Behavioral Health’s receptionist it was made clear—The therapists do not fill out
paperwork for court or child custody issues.




                           Agreement Regarding Missed or Cancelled Appointments

           1. I understand and agree it is my responsibility to notify Arrowhead Behavioral Health at
           623-876-1246 24 hours prior to the scheduled appointment if I am unable to keep the
           scheduled appointment.

           2. I agree I will be billed the fee of $50.00 in the event I miss an appointment or fail to cancel
           24 hours prior to the scheduled appointment.

           3. I understand a fee charged for a No-show or Late Cancellation must be paid before I (the
           Patient) can reschedule. Fees must be paid in person by cash, credit card, or by phone with a
           credit card.

           Patient Signature:________________________________ Date:______________________

           Guardian’s Signature:_____________________________ Date:______________________
         REQUEST TO COMMUNICATE PATEINT CARE INFORMATION WITH YOUR PRIMARY CARE
                                 PHYSICIAN OR SPECIALIST


In an effort to provide continuity of care and as per request of your insurance company we are asking you to sign a
release of information to your primary care or referring physician. The only information that will be shared with your PCP
or specialist will be related to your medication or medical concerns.

PHYSICIAN’S NAME ____________________________________________________________________________

PHYSICIAN’S TELEPHONE NUMBER:______________________________ FAX NUMBER ______________________
Dear Doctor__________________:

Your patient:_______________________________________, date of birth:_________________

Was seen by Arrowhead Behavioral Health for an initial assessment on:_____________ with the next visit

Scheduled on:_______________________________.

DIAGNOSIS OR PRESENTING PROBLEM:___________________________________________________

TREATMENT
RECOMMENDATIONS:________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

MEDICATIONS
PRESCRIBED:_______________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________

If further information is required contact Arrowhead Behavioral Health’s office at:
         9865 W Bell Rd.
          Sun City, AZ 85351
          623-876-1246 or Fax 623-933-5463



______________________________________________________________________                       ____________________________________________
CLINICIAN                                                                                    DATE



                                                       Authorization To Disclose Information

To the party receiving this information: This information has been disclosed to you from records whose confidentiality is protected by federal law.
Federal regulations 42 CFR Part 1, prohibit you making further disclosure of it without the specific written consent of the person to whom it pertains, or
as otherwise permitted by such regulations. A general authorization for release of medical or other information is not sufficient of this purpose.

                                  FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2

_____________I want this information released to my physician.

_____________I do not want this information released to my physician.


PATIENT’S SIGNATURE:__________________________________________________________ DATE _________________________________




PARENT/GUARDIAN’S SIGNATURE: _________________________________________________ DATE: _________________________________
                                           THIS IS YOUR COPY TO KEEP

                                  ARROWHEAD BEHAVIORAL HEALTH CENTER

                                            CLIENT RESPONSIBILITIES

    1    Clients will have a responsibility to provide accurate and complete information about their presenting
         complaints. past illnesses. hospitalizations, medications and other matters relating to their health.
    2.   Clients will have a responsibility to report any present, recent or past problems in response to or
         compliance with casework guidance and management, recommended counseling or treatment plans.
         prescribed medications (including mood and/or behavior modifying medications).
    3.   Clients will have a responsibility to make it known to the assigned counselor whether they clearly
         comprehend the recommended treatment plan and their role in the treatment process,
    4.   Clients will have a responsibility for following the recommended treatment plan and reporting any
         problems encountered, together with any significant changes in their condition.
    5.   Clients will have the responsibility for keeping appointments and for notifying their assigned counselor
         when they are unable to do so 24 hours prior to session.
    6.   Clients will have a responsibility for their actions in and consequences of refusing to comply with or
         follow the recommended treatment plan.
    7.   Clients will have a responsibility to follow agency rules and regulations affecting client treatments.
         ,conduct on the premises including the grounds and parking lots. These include smoking regulations
         noise regulations.
    8.   Clients will have a responsibility for being considerate of the rights of others including the assigned
         counselor. Profanity, verbal abuse and/or threats involving staff will be grounds for discharge from
         agency.
    9.   Clients will have a responsibility for being respectful of the right and property of other clients, the staff
         and the agency.
   10.   Clients will have a responsibility for the care of basic personal hygiene, grooming and dressing
         appropriately.
   11.   Clients will have a responsibility for assuming whatever financial obligation may be involved in their
         treatment and the obligation is to be fulfilled as promptly as possible (where applicable).

                                         CONFIDENTIALITY INFORMATION

A client's confidentiality is important and is legally protected. There are however, circumstances that impose
limitations on a client's right or ability to maintain a privileged communication. We are legally bound to report
suspected child or elder abuse or neglect, and are obligated to take steps to inform others if there is a reason to
believe that a client is a danger to themselves or others. Confidentiality may also be waived as a result of a court
order, legal proceeding, referral to a licensing authority, or other statutory requirement. When a clinician is out
of town, another professional will cover crisis calls and that professional may be advised of issues that might
arise on your case. If a health benefit plan is expected to pay for some portion of the cost of services, it must be
mutually understood and accepted that this office may furnish diagnostic, financial, and clinical information to
insurance companies, and/or medical review organizations in order to obtain reimbursement. Your case may be
subject to a Peer Case File Review to insure the highest quality of care. In the event group counseling services
are provided, it is further acknowledged that the therapist or practice cannot be held responsible for a breech of
confidentiality on the part of a peer group member.

                                               HOURS/AVAILABILITY:

The administrative office is typically open from 9:00 am. to 5:00 pm. Monday through Friday. In the event that it
is urgent that you reach your therapist, please call 389-9590 and leave a voice mail or punch in your number and
someone will call you back shortly. In the event that a crisis exists and you are unable to wait for your call to be
returned please call the crisis phone number on the back of your healthcare card, the Mental Health Crisis phone
at 222-9444, 911, or go to an emergency room.
                                                     Statement of Client Rights


1. To be treated with dignity, respect, and consideration;
2. Not to be discriminated against based on race, national origin, relation, gender, sexual orientation, age, disability,
    marital status, diagnosis, or source of payment;
3. To receive treatment that;
          a. Supports and respects the client’s individuality, choices, strengths, and abilities;
          b. Supports the client’s personal liberty and only restricts the client’s personal liberty according to a court order, by the client’s
               consent , or as permitted by Arizona Department of Health Services, A.A.C, Title 9, Chapter 20; and
          c. Is provided in the least restrictive environment that meets the client’s treatment needs;
4. Not to be prevented or impeded from exercising the client’s civil rights unless the client has been adjudicated
    incompetent or a court competent jurisdiction has found that the client is unable to exercise a specific right or
    category of rights.
5. To submit grievances to ABH staff members and to outside entities and other individuals without constraint or
    retaliation;
6. To have grievances considered by ABH in a fair, timely, and impartial manner;
7. To seek, speak to and be assisted by legal counsel of the client’ choice, at the client’s expense;
8. To receive assistance from a family member, designee in understanding, protecting, or exercising the client’s rights;
9. If enrolled by Arizona DHS or a RBHA as an individual who is seriously mentally ill, to receive assistance from
    human rights advocates provided by DHS or a designee in understanding, protecting, or exercising the client’s rights;
10. To have the client’s information and records kept confidential and released only as permitted under DHS Title 9,
    Chapter 20, R9-20-211;
11. To privacy in treatment, including the right not to be fingerprinted, photographed, or recorded without consent,
    except for photographing for identification and administrative purposes, as provided by A.R.S. 36-507(2);
12. To review, upon written request, the client’s own record during agency hours of operation or at a time agreed upon
    by the Clinical Director, unless the client’s physician determines that the client’s review of the client record is
    contraindicated and documents the reason for the determination in the client record;
13. To review the following at ABH or at Arizona DHS:
          a. Arizona DHS, Title 9, Chapter 20, rules for behavioral health service agencies;
          b. The report of the most recent inspection of the premises conducted by Arizona DHS, Office of Behavioral Health Licensure;
          c. A plan of correction in effect as required by Arizona DHS, Office of Behavioral Health Licensure;
14. To be informed of all fees that the client is required to pay and of ABH’s refund policies and procedures before
    receiving a behavioral health service, except for a behavioral health service provided to a client experiencing a crisis
    situation;
15. To consent to treatment, unless treatment is ordered by a court of competent jurisdiction, after receiving a verbal
    explanation of the client’s condition and proposed treatment, including the intended outcome and the nature of the
    proposed treatment, including any procedures and risks involved and any alternatives to the proposed treatment;
16. To be offered or referred for the treatment specified in the client’s treatment plan;
17. To receive a referral to another agency if ABH is unable to provide a behavioral health service that the client
    requests or that is indicated in the client’s treatment plan;
18. To give general consent and, if applicable, informed consent to treatment, refuse treatment or withdraw general or informed consent to
    treatment, unless the treatment is ordered by a court according to A.R.S. Title 36, Chapter 5, is necessary to save the client’s life or
    physical health, or is provided according to A.R.S. § 36-512.
19. To be free from: abuse; neglect; exploitation; coercion; manipulation; retaliation for submitting a complaint to
    Arizona DHS or another entity; discharge or transfer or threat of discharge or transfer for reasons unrelated to the
    client’s treatment needs, except as established in a fee agreement signed by the client or the client’s legal agent;
20. To participate, or if applicable, to have the client’s legal agent participate in treatment decisions and in the
    development and periodic review and revision of the client’s written treatment plan;
21. To control the client’s own finances except as provided by A.R.S. 36-507(5);
22. To participate or refuse to participate and to consent in writing or to withdraw written consent for participation in
    research, experimental treatment, or treatment that is not professionally recognized treatment;
23. To refuse to acknowledge gratitude to ABH through written statements, other media, or speaking engagements at
    public gatherings;
24. To receive behavioral health services in a smoke-free facility, although smoking may be permitted outside the facility;
25. To receive, at the time of discharge or transfer, recommendations for any treatment needed when the client is
    discharged.
26. To refuse to perform labor for an agency, except for housekeeping activities and activities to maintain health and personal hygiene.
27. To participate or refuse to participate in religious activities;
28. To be compensated according to state and federal law for labor that primarily benefits the agency and that is not part of the client’s
     treatment plan.
    ARROWHEAD BEHAVIORAL HEALTH is located just East of Access Bank and behind Carrows
          Restaurant at 99th Ave. and Bell Rd. The Back building of Campana Square.

If you are coming from the 101 and Bell Rd. turn left on 98th Ave. (Coco's is on the corner). Then take
 an immediate right on Campana and go all the way to the end of the long building and turn right in to
            the lot. We are the end suite of the building on the right. (ABH in yellow letters).

    If you are approaching from West Bell Rd, go through the light at 99th Ave. and turn right into the
    Carrows parking lot and drive all the way to the back building and we are in the end suite (ABH in
                                             yellow letters).
           N


                          ARROWHEAD BEHAVIORAL HEALTH
W                              E
                                       9865 W. Bell Rd. Sun City, Arizona 85351
                                               PHONE: 623-876-1246
                                                 FAX: 623-933-5463
            S


                                   On the Run                             Post Office
                                   (Gas Station)         W. BELL RD.


                                                                              Coco’s
                                   Bank            X
                                                                ↓             Rest.
                                           CARROWS
                                                            CAMPANA SQUARE
                   99th AVE.




                                                                                        98th AVE.
                                          RESTAURANT




                                                                       Other shops
                                      Parking
                                                          ABH          in strip mall
                                      lot


                                                       CAMPANA DR.


           Please fill out all paperwork to the best of your ability. DO NOT fax or email these
            papers back to us; we need an authentic signature—bring them with you to your
            appointment, along with your insurance card or drop them off at our office before
                                        your scheduled appointment.

                                                       www.abhpsych.com

     We accept all major credit cards, debit cards, checks, and cash. We also take payments over the phone:
                                                   623-826-1246

				
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