Consumer Application Intake Form

1Client Intake

2Consumer Case

3Client Orientation

4Client Rights

5Client Grievance Procedure

6Admission Agency Agreement

7Agency Rights

8Emergency Plan

9Consent to Emergency Treatment

10Transportation Waiver

11Emergency Preparedness Plan

12Emergency Back up Plan

13Release of Client

14Seizure Protocol

15Covid 19 Consumer/Employee Policy

URL

This field is for validation purposes and should be left unchanged.

A. GENERAL DESCRIPTION OF APPLICANT:

Name(Required)

First Middle Last

Place of Birth(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Social Security #(Required)

Phone(Required)

Height/Weight(Required)

Medicaid #(Required)

Diagnosis(Required)

B. FAMILY AND SIGNIFICANT OTHERS:

PERSON / LEGAL REPRESENTATIVE(Required)

Phone(Required)

Address(Required)

CHILDREN / SIBLINGS

Phone

Address

OTHERS

Phone

C. PERSON TO NOTIFY IN CASE OF EMERGENCY

NAME(Required)

RELATIONSHIP(Required)

Address(Required)

NAME:(Required)

RELATIONSHIP:(Required)

Address(Required)

D. SERVICE PROVIDERS

AALPHA RESOURCES, LLC

985.248.4496

ADDRESS: 13322 HIGHWAY 90, STE, K – PO BOX 1032, BOUTTE, LA 70039

SHARONDA BAHAM-LAGRANGE

E. MEDICAL & PROFESSIONAL INFORMATION

MEDICAL DIAGNOSIS:(Required)

F. PROFESSIONAL CONTACT

PHYSICIAN:(Required)

ADDRESS:(Required)

Phone(Required)

PSYCHIATRIST(Required)

ADDRESS:(Required)

Phone(Required)

G. MEDICAL AND HEALTH INFORMATION:

MEDICATION:

CONDITION:

DOSAGE:

Can consumer administer own medication?(Required)

Yes

Medication Allergies?(Required)

Yes

If no, please explain:(Required)

If yes, please explain:(Required)

H. MEDICAL HISTORY

Does the consumer have a hearing impairment?(Required)

Yes

Any history of serious physical history?(Required)

Yes

If yes, list illness and dates:(Required)

Does consumer have speech impairment?(Required)

Yes

If yes, Describe(Required)

Is consumer verbal?(Required)

Yes

If no, communication mode(Required)

Does consumer have a visual impairment?(Required)

Yes

If yes, Describe(Required)

Does consumer have seizures?(Required)

Yes

If yes, Describe(Required)

Does consumer have a mobility impairment?(Required)

Yes

If yes, Describe(Required)

Has Consumer ever had any serious emotional problems?(Required)

Yes

If yes, Describe(Required)

Is Consumer presently attending a mental health center?(Required)

Yes

If yes, Describe(Required)

I. Mobility

Does consumer need accessible housing?(Required)

Yes

If yes, Describe(Required)

Does consumer use wheelchair?(Required)

Yes

Type of Wheel Chair(Required)

Electric

Manual

Does consumer uses braces?(Required)

Yes

Crutches:(Required)

Yes

Hearing Aid(s):(Required)

Yes

Glasses/Contacts:(Required)

Yes

Adaptive Equipment:(Required)

Yes

Does consumer need an attendant?(Required)

Yes

If yes, Describe(Required)

Can consumer self-evacuate from his/her home in case of emergency?(Required)

Yes

If no, explain(Required)

When was your last visit to?

Physician

MM slash DD slash YYYY

Clinic:

MM slash DD slash YYYY

Therapist

MM slash DD slash YYYY

Mental Health:

MM slash DD slash YYYY

CONSUMER CASE RECORD

Consumer Name

Consumer Address(Required)

Phone(Required)

Social Security Number:(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Medicaid #(Required)

Medicare(Required)

Private Insurance(Required)

Primary Diagnosis:(Required)

Marital Status:

Consumer Living Status:(Required)

Consumer Employment Status:(Required)

Family Member Name:(Required)

Relation to Consumer:(Required)

Telephone Number:(Required)

Alternate (cell)(Required)

Primary Care Physician(Required)

Address(Required)

Phone(Required)

Secondary Care Physician Therapist etc.(Required)

Address(Required)

Phone(Required)

Dental Care Provider(Required)

Address(Required)

Phone(Required)

CONSUMER ASSESSMENT

Hearing Impairment(Required)

Yes

Speech Impairment(Required)

Yes

Verbal(Required)

Yes

Visual Impairment(Required)

Yes

Artificial Limbs(Required)

Yes

History of Mental Illness(Required)

Yes

History of Seizures(Required)

Yes

Mobile Impairment(Required)

Yes

Wheelchair(Required)

Yes

Scooter(Required)

Yes

Cane/Walker(Required)

Yes

CONSUMER EMOTIONAL STATUS:

Alert(Required)

Yes

Happy(Required)

Yes

Depressed(Required)

Yes

Coherent(Required)

Yes

Combative(Required)

Yes

Nourished(Required)

Yes

Malnourished(Required)

Yes

List all known Allergies:

Consumer Home Assessment:

Additional Comments

CONSUMER EMERGENCY CONTACT:

Name

Relations

Home

Cell

CLIENT’S ORIENTATION

Consumer Name

Each client must receive orientation in all the following areas within (7) days of admission to AALPHA RESOURCES, LLC. The staff member responsible for orienting each area should initial once the orientation is complete and then have the client sign and date at the bottom of the sheet to indicate that they have completed all their orientation.

1. Responsibility of Organization
2. Work Program Rules
3. Non-discrimination Provisions
4. Clients Right and Responsibilities
5. Grievance and Appeal Procedure for Clients
6. Instruction in evacuation from the building
7. Instruction in contacting police, fire, and other emergency Services
8. Instruction in fire and accident prevention

Consumer/Legal Guardian Signature (If Applicable)(Required)

Date

MM slash DD slash YYYY

Aalpha Staff Signature(Required)

Date

MM slash DD slash YYYY

CLIENT’S RIGHTS AND RESPONSIBILITY

Consumer Name:(Required)

Phone(Required)

Address:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

SSN(Required)

Medicaid #:(Required)

Recipients of personal care services have the following rights:

• To be treated with dignity and respect.

• To receive services according to the approved Plan

• To change providers after every 3 months without good cause or any time with good cause.

• To actively participate in the development of the Plan.

• To have freedom of choice in the selection of a provider.

• To actively participate in the decision-making process regarding service delivery.

• To have an informal resolution process to address complaints and/or concerns.

• To keep the Agency abreast and to reports any unethical and unprofessional behavior.

Consumer/Legal Guardian Signature (If Applicable)(Required)

Date

MM slash DD slash YYYY

Aalpha Staff Signature(Required)

Date

MM slash DD slash YYYY

CLIENT’S GRIEVANCE PROCEDURE

Procedures for Filing Grievance:

Contact the office immediately and report the grievance to the Agency Supervisor or personnel department. The Agency Supervisor or an authorized representative of the agency will schedule a one-on-one meeting with the consumer and staff involved to discuss the grievance; all information collected will be documented in writing.

Based on the information collected in the one-on-one meeting with consumer and staff involved the agency will review all party's grievance and make a final determination within 3 working days.

The Supervisor or Agency authorized representative will contact the consumer and discuss a resolution to the grievance. If the resolution to the grievance is not to the client's satisfaction, the agency Program Director will be notified, and further action will be taken.

Within 5 working days, the Program Director will review the documented meeting notes as well as the Supervisor or authorized representative and make a decision in regard to the matter at hand.

The Program Director will contact the client and inform him/her of the decision. This process will be 2 days after the Program Director reviews the document notes.

If for any reason the client is still not satisfied with the solution, the client has the right to an appeal. The appeal will be handed down to the Client' Rights Officer who will in turn review all documented notes on the surrounding circumstances.

This process could take up to 4 working days. The client's rights offices may choose to re-interview both parties as well as the client family members to determine the final course of action.

The Client's Rights Officer will contact the consumer directly and inform him/her of the final solution to resolve the matter. At this stage the grievance has exhausted all levels, if at this point the client is still dissatisfied, the client may contact the Office of Behavioral Health or Health Standards Department.

All levels of resolution will be documented and kept in the clients' binder as well as the staff personnel file.

Consumer/Legal Guardian Signature(Required)

Date

MM slash DD slash YYYY

Aalpha Staff Signature(Required)

Date

MM slash DD slash YYYY

ADMISSION AGENCY AGREEMENT TO PROVIDE SERVICE

Consumer Name:

Date of Admission

MM slash DD slash YYYY

I, Consumer Name, hereby give my consent and authorization to my selected Personal Care Provider herein named A-Alpha Resources, LLC and its associates, to accompany and assist me in the home and with community-based assessment, care planning and service delivery processes. AALPHA RESOURCES, LLC will provide me with responsible Mental Health Specialists who will assist in aiding me with my Activity of Daily Living as well as my Instrumental Activity of Daily Living in accordance with my state approved consumer plan of care.

I, Consumer Name, understand that my plan of care may change and if so, all changes will be discussed and documented by an authorized representative of the Agency.

I agree

Must read full statement to select the agree check box

RELEASE OF INFORMATION

I, Consumer Name, hereby consent and authorize AALPHA RESOURCES, LLC to disclose and release information pertaining to the welfare of my clinical record to my health care provider, third party payer, utilization review, professional standard
review organizations’, regulatory review entities, accreditation reviewers and any other organizations, companies, community resources, etc., that may assist me in meeting my health care/home care needs.

I agree

LIABILITY FOR PAYMENT

All deductibles, co-payments, or balances due to the Agency after services have been billed and payment has been rendered, it is the responsibility of the individual to pay all such amounts due thereafter. I certified that all liability for payment information given is true and correct to the best of my knowledge; in addition, this admission agreement is applicable only to this admission to our agency.

I, Consumer Name, understand that the services provided to me by AALPHA RESOURCES, LLC is funded and billed to the following:

Medicare:

Private Insurance Company:

Direct Billing or by my Guarantor:

Third Party Payer:

Consumer/Legal Guardian Signature(Required)

Date

MM slash DD slash YYYY

Aalpha Staff Signature(Required)

Date

MM slash DD slash YYYY

AGENCY RIGHTS AND RESPONSIBILITY

AALPHA RESOURCES, LLC has developed the following policy and procedures in regard to the Agency rights and responsibility to the consumer.

The following are responsibility of the Agency:

• It is the responsibility of the agency to adequately staff all consumers.

• It is the responsibility of the agency to provide qualified Mental Health Specialist to our consumers.

• It is the responsibility of the agency to protect and maintain our consumers confidential information.

• It is the responsibility of the agency to maintain sufficient health care in accordance with the state approved consumers plan of care.

• It is responsibility of the agency to maintain open lines of communication for our consumers at all times.

• It is the responsibility of the agency to provide quality health care services to our consumers to the best of our ability.

The following are rights of the Agency:

• It is the right of the agency to conduct monthly supervisory visits as well as quarterly home assessment of our consumer living conditions.

• It is the right of the agency to request health information on our consumers in relations to proper health care management.

• It is the right of the agency to terminate or discharge the consumer in the event the consumer becomes combative, disrespectful to staff, or unwilling to accept staffing provided by the agency.

The following are rights and responsibility of the Agency:

• It is the right and responsibility of the agency to report all suspected signs of abuse, neglect, misappropriation, exploitation etc. that may arise in regard to the maintaining the health and safety of the consumer. These are the basic rights and responsibility of the Agency, however defined, the Agency's first and far most duty is to maintain the health and safety of our consumers.

Consumer/Legal Guardian Signature(Required)

Date

MM slash DD slash YYYY

Aalpha Staff Signature(Required)

Date

MM slash DD slash YYYY

EMERGENCY PLAN

CONSUMER CONSENT TO EMERGENCY TREATMENT

Consumer Name

DOB

MM slash DD slash YYYY

Address:

Phone

First Aid

I, Consumer Name authorize AALPHA RESOURCES, LLC to administer First Aid and/or access EMS (Emergency Medical Services) by calling 911.

Yes

CPR

I, Consumer Name consent to CPR being administered by EMS.

Yes

Consumer/Legal Guardian Signature

Date

MM slash DD slash YYYY

Aalpha Staff Signature

Date

MM slash DD slash YYYY

EMERGENCY PREPAREDNESS PLAN

Consumer Name

DOB

MM slash DD slash YYYY

Address:

Phone

fire(Required)

In the event there is a fire in the consumer home, the DSW/PCA if on duty, will stop all activities and immediately escape to the closest visible exit. If the fire consumes the client, the DSW/PCA is trained to stop the client, drop the client, and roll the client till the fire dissipates. The DSW/PCA is trained to immediate contact 911 followed by the Agency and nearest family or legal Guardian. I, Consumer Name understands and agree to be a willing participant in the Agency monthly fire drills as it is a practice to better aid me in my evacuation procedures as well as my health and safety.

I understand and agree

flooding(Required)

In the event the area you reside in is flooded, the DSW/PCA if on duty will assist you to higher ground or if possible, evacuate the home. If the DSW/PCA is not on duty, you are to still proceed to higher ground. If possible, call 911 and await further instructions.

I understand and agree

NDTH(Required)

In the event of a natural disaster secure yourself to a stable doorframe in your home. If DSW/PCA is on duty, the DSW/PCA will listen to the local new casting, radio stations etc. for instruction of mandatory evacuations if mandated by the State of Louisiana and Government Officials. If possible, contact the office or your supervisor immediately and inform them of any situations that deems necessary. In the event of a tornado the DSW/PCA, if on duty, will secure themselves as well the consumer to a stable location in the home, preferably a bathroom tub, under a dining room table, or the doorway of a bedroom, bathroom or kitchen. Stay away from windows and any glass surfaces as the glass may break and cause harm to you and or the Staff.

I understand and agree

Consumer/Legal Guardian Signature

Date

MM slash DD slash YYYY

Aalpha Staff Signature

Date

MM slash DD slash YYYY

EMERGENCY BACK UP PLAN

Consumer Name

DOB

MM slash DD slash YYYY

Address:

Phone

EBU

In the event the State of Louisiana has issued a mandatory evacuation ________________________, I Consumer Name will evacuate with NAME /relations to consumer RELATIONSHIP .

I understand and agree

LOCAL EVACUATION PLAN:

Name

Phone

Address:

Transportation Type:(Required)

Transportation Other(Required)

OUT OF TOWN EVACUATION PLAN:

Name

Phone

Address:

Transportation Type:(Required)

Transportation Other(Required)

In case of additional assistance, you may contact: HEALTH STANDARDS HELP LINE: 1-225-342-0138

Consumer/Legal Guardian Signature

Date

MM slash DD slash YYYY

Aalpha Staff Signature

Date

MM slash DD slash YYYY

RELEASE OF CLIENT CONFIDENTIAL INFORMATION

Release(Required)

I/we authorize AALPHA RESOURCES, LLC to release and/or receive information in the interest of Consumer Name , service recipient, including psychological, social, and medical evaluation monthly progress summaries, and plans of care, to/from authorized employees within this agency and to/from the case manager.

I understand and agree

Consumer/Legal Guardian Signature

Date

MM slash DD slash YYYY

Aalpha Staff Signature

Date

MM slash DD slash YYYY

SEIZURE PROTOCOL

Release(Required)

In the event Consumer Name , has a seizure, AALPHA RESOURCES, LLC, Inc., has developed the following protocol for seizures.

I understand and agree

• STAY CALM – Never attempt to restrain the consumer having a seizure. Let the seizure take its course. Remember, a person having a seizure is not always aware of his/her actions or surroundings and may not be able to hear or acknowledge you.

• TIME THE SIEZURE – If the seizure repeats or lasts longer than five (5) minutes call for medical attention (911).

• PROTECT THE CONSUMER FROM INJURY

o Help guide the consumer to the floor if possible

o Put something soft under his/her head

o Move hard or sharp objects away from the consumer

o Loosen tight clothing, such as necktie or scarf.

o If the consumer begins to wander, stay by his/her side and gently steer them away from danger

o If the consumer is in a wheelchair, ensure the chair is in the “partial recline” position and brakes are locked on to protect from injury.

• NEVER INSERT ANYTHING INTO THE CONSUMER’S MOUTH • AFTER THE SEIZURE SUBSIDES – If possible, roll the consumer onto his/her LEFT side. If in a wheelchair, still in “partial recline” position, turn the consumer’s head to the side.

o Speak in a gentle, quiet and friendly voice to the consumer.

o Be comforting and reassuring to the consumer as he/she may be confused and disoriented. o Help maintain the consumer’s dignity by moving onlookers away, if possible.

o Remain with the consumer until full consciousness returns and offer assistance. DIAL 911 WHEN…

• Seizure lasts longer than 5 minutes or repeats without full recovery

• Head is hit during a seizure

• Unusual pain felt after the seizure

• Consciousness does not return after the seizure, or confusion last for more than an hour. All Staff has been orientated on the general first response protocol for Seizures.

Consumer/Legal Guardian Signature

Date

MM slash DD slash YYYY

Aalpha Staff Signature

Date

MM slash DD slash YYYY

COVID- 19 CONSUMER/EMPLOYEE POLICY

As a consumer of A-Alpha Resources, LLC, we would like to inform you that ALL Employees are recommended to be fully vaccinated for COVID-19. However, it is the employees right to be vaccinated or not. Fully vaccinated is defined as having ALL vaccinations that protects/prevents individuals from spreading/contracting Covid-19.

Our agency follows guidelines implemented by the Centers for Disease and Control, the Louisiana Department of Health, and policies enacted by A-Alpha Resources, LLC regarding Covid-19. You are aware and agree of the agency’s policy regarding Covid 19.

Please note in the event you or a family member within your home has been exposed to Covid-19, you agree to inform the DSW/PCA and A-Alpha Resources, LLC immediately. The most updated guidelines set by the Louisiana Department of Health (LDH) and the Centers for Disease (CDC) will be enforced.

By signing this document, you are clear of our policy regarding Covid 19.

You agree to abide by the following:

General Safety Tips

• Wear a medical face mask upon request by a consumer.

• Wash hands and clean the room between all patient appointments.

• Use eye protection if needed (based on level of community transmission).

• Wear gloves when in contact with bodily fluids.

• Change gloves between each patient and maintain proper hand hygiene.

• Agree to continue to always use universal precautions.

Consumer/Legal Guardian Signature

Date

MM slash DD slash YYYY

Aalpha Staff Signature

Date

MM slash DD slash YYYY