Admissions Intake

Financial Agreement

Insurance:

As a courtesy and in consideration of the Services to be rendered to the Signatory, Choice and or its’ authorized agents, may bill and is authorized by the Signatory to submit claims to the applicable insurance plan for the daily published rates outlined in Exhibit “A”. Choice is an out of network provider, meaning that a plan must have applicable out of network coverage to cover the cost of Services.

Choice will verify coverage and benefits with the applicable insurance carrier prior to upon admission. This is called a Verification of Benefits (“VOB”). A quotation of coverage or VOB is not a guarantee of payment by the insurance plan. It is the Signatory responsibility to ensure all information is provided to Choice.

As requested and is accurate and correct when utilizing Insurance as a form of payment.

The Signatory hereby states that he/she has authority to authorize the VOB, submission of claims and any and all other activities relating to the payment of Services under the applicable insurance plan.

The Signatory also warrants and represents that the insurance plan information disclosed to Choice and that which is anticipated to cover the costs of Services under this Agreement has not and shall not lapse, terminate, change or be reduced in any material way throughout the duration of Services under this Agreement.

The Signatory also represents that the insurance plan being utilized for Services has in no way been fraudulently purchased or paid for by a third party (exclusive of immediate family members).

In order to facilitate the payment of claims by the insurance plan, the Signatory hereby irrevocably assigns the right of payment and any ownership interest in funds that are dispersed directly to him/her to Choice.

In conjunction with this Agreement, Signatory and/or required party shall execute an Assignment of Benefit, and assign and authorize Choice all rights to appeal, communicate and provide any other functions required to obtain reimbursement from the insurance plan for services rendered by Choice.

Should the insurance plan fail to remit payment within 90 days to Choice, deny coverage, not cover a service or retro-actively deny claims, the Signatory hereby jointly and severally obligates himself/herself to pay any outstanding balance due to Choice at the daily-published rates for Services in addition to any Patient Responsibility that may be due under the insurance plan.

The Signatory understands that should the insurance plan pay for partial Services billed, regardless of the determination or reason held by the insurance plan, the Signatory shall still be jointly and severally liable for payment of all Services not paid for by insurance at the daily published rates listed in Exhibit “A”. All Statements are due upon receipt.

“Patient Responsibility” is separate and apart from the payments due from the insurance plan and include the insurance plan deductible, out of pocket, co-insurance and/or co-payments due under the applicable plan. Any amounts paid by the Signatory shall be held as a deposit towards Patient Responsibility and/or non-covered Services.

Choice reserves the right to bill the Signatory for amounts that the insurance company deems to be Patient Responsibility per the Explanation of Benefits provided by the insurance company.

Signatory also clearly understands that he/she is responsible for all Patient Responsibility under the insurance plan and must either make a deposit upon admission towards such costs, make payments during the course of Services and/or upon receipt of statements upon discharge. Choice is prohibited by law (Fl. Stat. §817.234) from waiving or not collecting Patient Responsibility. In the event the Signatory receives any payment directly from the insurance plan for services rendered by Choice, Signatory agrees to immediately endorse any such payment and forward directly to Choice. Signatory further agree that s/he shall have no ownership interest in any insurance check(s) issued by the insurance plan for payment for Services provided by Choice.

To be clear, the signatory has acknowledged and agreed that s/he has no ownership or property interest in checks issued by insurance plan for Services rendered by Choice and that any checks issued by insurance plan for Services rendered are the sole property of Choice. Failure to endorse any such payments to Choice may subject Signatory to certain statutory penalties, including that of §
772.11, NJ Statutes (Civil Theft).

Service Rate

Assignment Of Benefits

whether signing as subscriber, guardian, guarantor, agent, or as patient, (hereinafter “Signatory”), hereby irrevocably assign and transfer to Choice Point, and/or any of its affiliated companies, partner companies, subsidiaries, sister-companies, holding companies, divisions, or other forms of related ownership, owned in whole or in part by Choice Point and/or its majority interest holders.

(collectively referred to as the “Assignee” or “Choice Point”), its successors, agents and assignees as my beneficiary all rights to any and all insurance benefits which are or may become due to me, together with any and all actions, causes and action, suits, debts, sums or money, accounts, covenants, contracts, promises and interest in, or which I might acquire an interest against (“Insurance Carrier”), in accordance with its obligations to me arising under a certain policy of insurance.

(under which I am either the insured, subscriber or a covered dependent) for hospital, medical, chemical or substance abuse dependency services and other health care services (“Services”) rendered by the Assignee.

To be clear, I hereby authorize and request the Insurance Carrier to pay directly to Assignee the amount due to me for any and all claims for Services rendered and appoint Assignee to act as my
representative on behalf of any proceeding that may be necessary to seek payment from the Insurance Carrier.

I authorize Assignee all rights to appeal, communicate, obtain any and all files, papers, documents, correspondence, determinations, including, but not limited to, any and all reports, plan
documents, medical records, notes on attendance and/or treatment, memoranda, charts, tests, correspondence, billing records, payment ledgers, insurance cards or other health insurance
information, appeal determinations and any and all documents whatsoever in the Insurance Carrier, and/or its agents’ possession pertaining to the Services rendered by ChoicePoint , as well as
all other acts which may be helpful and appropriate to the accomplishment of such purposes, for the ultimate objective of payment for ChoicePoint ’s Services and shall cooperate as needed with
Assignee to obtain any information necessary to complete such purposes.

I authorize Assignee all rights to institute, prosecute and/or defend litigation, arbitration and/or other dispute resolution proceedings against my Insurance Carrier, and/or third party payers,
including but not limited to any and all administrative appeals which may be a condition precedent to litigation and/or any other dispute resolution proceedings, and to settle or compromise all
claims and/or disputes with my Insurance Carrier, and/or third party payers, for claims related to Services rendered by Assignee. This includes, but is not limited to, acting on my behalf as my
authorized representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.503-1(b)(4), with respect to any healthcare expenses incurred as a
result of the services I received from Assignee.

I have been made aware of my rights under HIPAA, and all other applicable Federal and State regulations pertaining to the release of my health information and private confidential records. With
said knowledge, I authorize Assignee to disclose any and all written information to the Insurance Carrier and/or its designated representatives, or other third party, as necessary and as determined
by Assignee. Such disclosure shall be for reimbursement purposes for Services provided by Assignee. I have executed an Authorization Relating to Protected Health Information which may be
provided if necessary.

I hereby indemnify and hold the Assignee harmless against any and all claims that have arisen or may arise with respect to the subject matter of this Assignment of Benefit. I also release Assignee
its parent corporation, affiliates, subsidiaries, divisions, officers, agents, employees and any clinician, from any and all liability that may arise as a result of disclosure of information to the above
named Insurance Carrier or its designated representatives or other third parties.

Should the benefits with the Insurance Carrier be “Non-assignable”, I acknowledge and agree that any payments made to me directly by the Insurance Carrier for Services rendered are trust funds
to be delivered Assignee. I also acknowledge and agree herein that I have no ownership, title or property interest in the insurance check(s) issued for payment of Services provided by Assignee
and that I do hereby assign ownership or any related interest(s) in these funds to Assignee.

Moreover, I agree that if I receive any payment(s) for Services rendered by Assignee from the Insurance Carrier directly, upon receipt, I will mail the payment check(s) or draft to Assignee. I further
agree to endorse the payment check(s) payable to Assignee. In the alternative, my signature on this document authorizes any officer, director or employee of Assignee to endorse any check(s),
draft(s) or other negotiable instrument(s) representing insurance or third party proceeds payable in connection with Services rendered by Assignee.

Change of Address

If required by the type of insurance plan maintained by the Signatory, Choice shall request that the Signatory complete a temporary change of address by contacting the insurance plan directly and
requesting the address be temporarily changed to 23-00 Route 208 Suite 2-9, Fair Lawn NJ 07410. Execution of a temporary change of address does not change the liability of the Signatory to
provide payment and/or forward and endorse any insurance payments received by the Signatory to Choice for Services rendered. All obligations are maintained herein.

Medications, Lab Work, and other Ancillary Charges

Choice may utilize third party service providers, which may include independent physicians, recovery residences, laboratories, pharmacies, and other health care providers. These third party
service providers may bill you and/or insurance plan directly and apart from Choice for items not inclusive of Services within this Agreement, including but not limited to housing, transportation
costs, medication, emergency room charges, medical visits, or laboratory tests (hereinafter known as “Ancillary Services”).

Signatory understands that Ancillary Services are separate and apart for services provided by Choice and as provided for under this Agreement. Signatory authorizes any third party connected
with rendering Ancillary Services to submit claims to the applicable insurance plan and assign the right of payment for Ancillary Services to the applicable service provider. Scholarships and
discounts available from Choice do not apply to Ancillary Services.

Signatory also understands that s/he may be billed separately and apart for Ancillary Services and may receive statements, explanation of benefits or payments not affiliated with Choice. It is the
sole responsibility of the Signatory to communicate and forward any information required or received to the applicable third party for Ancillary Services.

Scholarship and Discounts

If eligible, as determined in the sole discretion of Choice, Signatory may qualify for a scholarship and/or discounted rate from the daily-published rates outlined in Exhibit “A”. Should Signatory qualify for a scholarship and/or discounted rate, such Addendum shall be attached and incorporated (Exhibit “C”). Application of scholarship and/or discounted rates are contingent upon successful
completion of the treatment program.

Early Termination of Care

Choice reserves the right to discharge a party from Choice for non-payment and/or noncompliance with policies and rules of the treatment program.

In the event that the Signatory voluntarily or involuntarily leaves prior to completion of treatment, any awarded scholarship and/or discounted rate will be rescinded, and the daily published rates in
Exhibit “A” will apply from the date of admission. Signatory shall also be responsible for the costs of all Ancillary Services received.

Any deposits paid by the Signatory and/or monies paid by an insurance plan up until the last date Services were rendered shall be applied to the amount due for Services per the daily published
rates. All other amounts due shall be billed to the Signatory.

Refund Policy

Signatory shall not be entitled to any refunds for Services rendered by Choice. This policy shall apply to all insurance proceeds, and any deposits paid by Signatory, including where a patient leaves the facility against medical advice or for a violation of program rules.

Choice may consider such request and in its sole discretion may modify the terms of the no refund policy and remit a refund to Signatory. A Signatory may make an application in writing for a refund or adjustment for any outstanding balance due or amounts paid for deposits only within 90 days of discharge.

Consequences of Non-Payment & Legal

Choice will make every effort to assist Signatory with meeting their financial obligations. However, in the event that the Signatory does not respond to our billing invoices or neglects to make
arrangements, we reserve the right to undertake all action necessary to collect for unpaid Services under this Agreement including but not limited to utilizing a collection agency, initiating litigation,
referring to a credit agency or skip tracing agency.

Any unpaid amount due shall accrue interest at a rate of one and one quarter percent (1.25%) of simple interest per month, which shall compound annually unless otherwise provided by New Jersey law, beginning forty-five (45) days after the date of the first billing statement issued by Choice to the Signatory.

In the event Choice initiates any effort to enforce this Agreement, collect any outstanding monies due to Choice, or litigate relating to the unpaid Services rendered by Choice under this Agreement, the Signatory shall be responsible for all damages, applicable interest, court costs, attorney fees, collection fees, and any and all other costs related to the such collection or legal action. In all other legal actions brought by either the Signatory, non-party and/or a third party, the prevailing party shall be entitled to court costs, attorneys’ fees, collection fees, and all other costs related to the legal action.

The laws of the State of New Jersey govern this Agreement and all of the Exhibits and documents incorporated herein. The exclusive venue and jurisdiction for any legal action relating to this Agreement is in the state courts of Bergen County, New Jersey.

This Agreement represents the entire understanding between Signatory and Choice regarding its contents and it supersedes all prior agreements or understandings, whether written or oral, between the Parties and with respect to its subject matter. No amendment, change, modification, or alteration of the terms and conditions of this Agreement will be binding unless in it is writing and signed by both Parties.

If any provision within this Agreement are found by any court having jurisdiction to be invalid or unreasonable then the provision herein contained shall nevertheless remain effective, but shall be deemed amended as may be considered to be reasonable by such court, and as so amended shall be enforced. It is also the intention of the Parties that the provisions of this Agreement shall be enforceable to the extent permissible under applicable laws, and that the invalidity or unenforceability of any provisions under such laws will not render unenforceable, or impair, the remainder of the Agreement. If any provisions of this Agreement are deemed invalid or unenforceable, either in whole or in part, this Agreement will be deemed amended to modify, or delete, as necessary, the offending provisions and to alter the bounds thereof in order to render it valid and enforceable.

This Agreement may be executed in one or more counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures evidenced by facsimile or electronically will be accepted as original signatures. By signing below, the Signatory affirms and asserts that is has read and understood the terms and conditions of this Agreement in full and are jointly and severally liable for payment of all Services, fees or monies due under this Agreement to Choice.

Signatory has had the opportunity to ask questions, understands this is a binding legal Agreement and is executing this Agreement freely and without inducement and with the intention to bound by the terms and conditions herein.

IN WITNESS WHEREOF, the Parties have executed this Agreement effective as of the Effective Date.

Release

Federal Privacy Act Versus Other Applicable Standards:

ChoicePoint assures you that we will take every measure to protect your rights to confidentiality and ensure the minimal necessary protected information is disclosed during routine health operations and inspections.

The purpose of this document is to advise you of your rights and our responsibilities under the Federal Privacy Act. Other State and federal laws regulate the disclosure of your health information as it pertains to medical/ mental health, substance abuse, and/ or HIV status. In addition, there are professional codes of ethics that set standards governing the conduct of behavioral health care professionals. When more than one standard applies, ChoicePoint Health will follow the most restrictive standard.

All patients of ChoicePoint Health are to be informed of the practices and policies in place. By signing this document, you are acknowledging your receipt and full understanding of the information
provided below.

Informed Consent:

Counseling and Substance Use Treatment is a relationship between people which works because of clearly defined rights and responsibilities held by each person. As a patient of ChoicePoint Health, you have certain rights and responsibilities that are important for you to understand. There are legal limitations to those rights you should be aware of. Your counselor also has corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Substance Use Treatment has both benefits and risks. Risks may include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process often requires discussing the unpleasant aspects of your life. Counseling has been shown to have benefits for individuals who undertake it. Counseling often leads to significant reductions in feelings of distress, increased satisfaction and interpersonal relationships, greater personal awareness and insight, increase in skills for managing stress, resolutions to your problems and reduction in unproductive habits and harmful coping skills. There are no guarantees about what will happen. Substance Use Treatment requires a very active effort on your part. To be successful, you will have to be open and honest in session and continue your goal progress both outside of program.

Conflicts of interest: 

Client shall be informed when a current or potential conflict of interest arises. ChoicePoint will take all reasonable steps to resolve any issues in a manner which protects client’s interest to the greatest extent possible. In some cases, protecting client’s interest may require termination of the professional relationship with proper referral of the client to an alternative treatment provider.

Dual Relationship and Example of Ethical Disclosures in Exceptional or unique circumstances:

ChoicePoint shall not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or harm to the client. In instances when dual or multiple relationships are unavoidable ChoicePoint will take steps to set clear, appropriate, and culturally sensitive boundaries. (dual relationships occur when counselors and clients take part in more than
one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or concurrently)

Disclosure:

Cases where ChoicePoint is unable to meet your therapeutic request or needs, referrals will be made to alternative treatment providers in the appropriate level of care required to meet patient
needs.

Appointments:

Individual Sessions will generally be 60 minutes long in duration and 1-2 times per week in frequency at a time agreed on. Intensive Outpatient Groups will be three hours In duration, include a 15 minute break, and occur 3-5 times per week, as needed. Outpatient Groups occur 1-6 rimes per week and generally last 90 minutes. Some sessions may be more or less frequent as needed. Medical Visits are by appointment only. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, it is asked you provide 24 hours’ notice via phone call. You are responsible for coming to and checking into your session on time; If you are late your appointment will still need to end on time.

Insurance:

ChoicePoint Health participates in the Medicaid Program. ChoicePoint Health is an out of network substance use treatment provider for all insurance companies, meaning there is no in-network
relationship between ChoicePoint Health and any private insurance company. If your insurance plan features out of network reimbursement benefits, your counselor will provide you at the end of each session, a receipt to submit to your insurance company. ChoicePoint Health does not submit receipts to insurance providers.

Confidentiality:

As a rule, ChoicePoint Health will disclose NO information about you, or the fact that you are a client of the agency without your written consent.

Limits of Confidentiality

ChoicePoint Health may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required.

1. EMERGENCY: You are involved in a life-threatening emergency and cannot be asked your permission; we will share information if I believe it may be pertinent to your immediate health. If you are unresponsive for more than 5 consecutive days, your emergency contact may be contacted for a welfare check or other inquiry into wellbeing.

2. CHILD ABUSE REPORTING: if there is a reason to suspect a child is abused or neglected, ChoicePoint Health will by law report to proper authorities immediately.

3. ADULT ABUSE REPORTING: if there is a reason to suspect that an elderly or incapacitated adult is abused neglected or exploited, ChoicePoint Health will by law report to the proper
authorities.

4. COURT PROCEEDINGS: if you are involved in court proceedings and a request is made for information about your diagnosis and treatment and a record there of such information is privileged, ChoicePoint Health will not release any records unless you provide written authorization. If a subpoena for records or testimonies received, you will be notified. If a judge issues a court
order specifically explaining request ChoicePoint Health will respond accordingly.

5. SERIOUS THREATS TO HEALTH AND SAFETY: if you communicate a specific and immediate threat to cause serious bodily injury or death to an identified or identifiable person, or ChoicePoint Health believes you have the intent and ability to carry out a threat immediately or imminently ChoicePoint Health is legally required to take steps to protect 3rd parties.

These progressions may include

1) warning the potential victim(s), or the parent or Guardian of the potential victim(s) if under 18
2) notifying a law enforcement officer
3) seeking your hospitalization

Uses and disclosures of information not covered by this notice or by the laws that apply to ChoicePoint Health will be made only with your written permission.

Other Rights: 

If you are unhappy with your counseling experience, please speak directly with ChoicePoint Health Management so we can respond to your concerns. Such comments will be taken seriously and
handled with care and respect. You may also file a grievance with the New Jersey Department of Human Services or New Jersey Office of Consumer Affairs. You 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. You have the right to ask questions about
any aspects of treatment and about staff’s specific training and experience.

Professional Disclosure:

We work with clients to address a number of identified issues. First and foremost, ChoicePoint Health has come to specialize in substance use treatment for adults age 18 and over. ChoicePoint Health has and does currently see many clients throughout the recovery and treatment process, struggling with a variety of issues. Some issues include relationships, parenting, social skills, coping skills, and other areas relating to sobriety and treatment. ChoicePoint Health strives to support clients who are struggling with sobriety through providing medical assisted treatment, ambulatory detoxification, Group Counseling, and Individual Counseling.

Level of care Offered

1. ASAM Level 1 – Outpatient Treatment
2. ASAM Level 2.1 – Intensive Outpatient Treatment
3. Co-Occurring Treatment
4. Medication Assisted Treatment
5. Ambulatory Detoxification
6. Partial Care

Treatment Process and Approach: 

Counseling is a process in which you the client should gain insights and tools, perspective shifts, and personal contexts which facilitate your own growth and development, both during and after
counseling has concluded. While many clients experience transformative shifts, we cannot guarantee results individually as each client is unique and has their own process/ growth curve. We will however discuss, examine, and reflect on progress taking place during Treatment.

Modality:

ChoicePoint Health generally utilizes evidenced based practices including CBT and a strength based, reality focused, goal oriented, client centered approach. Other modalities used may include
motivational interviewing.

Delivery:

Forms of treatment are delivered either through individual or group therapeutic environments, via in-person treatment in the Fair Lawn, NJ Location, or online via Sunwave EHR Software or
Google Meeting Tools. In-person counseling and online counseling both utilize HIPAA complaint technology such as Google Business Suite or Sunwave EHR Software..

Confidentiality of Mental Health, Alcohol & Drug Abuse Client Records

The confidentiality of mental health, alcohol abuse, drug abuse, and/or eating disorder Client records maintained by this program are protected by Federal laws and regulations. Generally, the
program may not say to a person outside the program that a Client attends the program, or disclose any information identifying a Client as an alcohol abuser, drug abuser or eating disorder
UNLESS:

1. The Client consents in writing;
2. The disclosure is allowed by a court order;
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation;
4. The Client reports thoughts of suicide or homicide;
5. The Client reports child or elder abuse.

Violation of the Federal laws and regulations by a program is a crime. Suspected violations may be reported to the appropriate authorities in accordance with Federal regulations.

Federal laws and regulations do not protect any information about a crime committed by a Client either at the program or against any person who works for the program or about any threat to
commit such a crime.

Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State of local authorities.

I understand that my records are protected under Federal Confidentiality regulations (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR Part 2 for Federal regulations) published August 10, 1987, and cannot be disclosed without my written consent unless other provided in the regulations. I understand that my medical record may contain information concerning
my psychiatric, psychological, drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions.

Confidentiality In Group

To reinforce the feelings of closeness and willingness to share with others your feelings, thoughts and consequences of your dependency, confidentiality is a must in group therapy. Use this as your golden rule: What is said in Group, stays in Group. To break this rule violates the trust of the total group and the effectiveness of group therapy is lost.

The following guidelines will help you maintain this rule:

1. Group issues are not discussed with others outside your group.
2. Do not discuss group issues with your roommate unless he/she is in your group.
3. Do not discuss at any outside meetings or places where others may overhear you.

Your group therapists have the same responsibilities for group confidentiality as you, with the exception that your therapists share group issues and your participation in the group process with
other staff members. This is a vital part of the staff team approach to assist you in your recovery.

The staff values your confidentiality so highly that anyone who breaks confidentiality - whether to another Client of ChoicePoint, or to family, significant others, etc., may be subject to discharge
from this program.

42 CRF Part II

In the substance abuse field, confidentiality is governed by federal law (42 U.S.C. § 290dd-2) and regulations (42 CFR Part 2) that outline under what limited circumstances information about the client's treatment may be disclosed with and without the client's consent.

Determining when 42 CFR Part 2 is applicable and how to legally access information about substance abuse treatment requires practitioners to work through a series of questions.

What Programs Are Covered by Federal Confidentiality Laws?

42 CFR Part 2 applies to any program that
l. Involves substance abuse education, treatment, or prevention and
2. Is regulated or assisted by the federal government (42 U.S.C. § 290dd-2; 42 C.F.R. 2.11- 2.12).

WHAT INFORMATION IS PROTECTED?

42 CFR Part 2 applies to all records relating to the identity, diagnosis, prognosis, or treatment of any patient in a substance abuse program that is conducted, regulated, or directly or indirectly assisted by any department or agency of the United States.

HOW CAN PROTECTED INFORMATION BE SHARED?

Information can be shared if written consent is obtained. A written consent form requires ten elements (42 C.F.R. 2.31(a), 45 C.F.R. 164.508(c)):

l. The names or general designations of the programs making the disclosure
2. The name of the individual or organization that will receive the disclosure
3. The name of the patient who is the subject of the disclosure
4. The specific purpose or need for the disclosure
5. A description of how much and what kind of information will be disclosed
6. The patient's right to revoke the consent in writing and the exceptions to the right to revoke or, if the exceptions are included in the program's notice, a reference to the notice
7. The program's ability to condition treatment, payment, enrollment, or eligibility of benefits on the patient agreeing to sign the consent, by stating
a) The program may not condition these services on the patient signing the consent
b) the consequences for the patient refusing to sign the consent
8. The date, event, or condition upon which the consent expires if not previously revoked
9. The signature of the patient (and/or authorized person)
10. The date on which the consent is assigned

When used in the criminal-justice setting, expiration of the consent may be conditioned upon the completion of, or termination from, a program instead of a date.

MANDATORY DISCLOSURES:

42 CFR Part 2 allows for disclosure where the state mandates child-abuse-and neglect reporting (42 C.F.R. §212(c)(6); 45 C.F.R. § 164.512(b)(1)(ii)). when cause of (42 C.F.R. § 2.15(b)) is being
reported; or with the existence of a valid court order.

PERMITTED DISCLOSURES:

Programs are permitted to disclose patient-identifying information in cases of medical emergency (45 C.F.R. § 164.506(c); 42 C.F.R. § 2.51); in reporting crimes that occur on program premises or against staff (45 C.F.R. § 164.502(j)(2), 164.512(f)(2); 42 C.F.R. § 2.12(c)(5)); to entities having administrative control (45 C.F.R. § 164.502(a)(1), 164.506(a), (c); 42 C.F.R. § 2.12 (c)(3)); to qualified service organizations (45 C.F.R. § 160.103, 164.504(e), (c); 42 C.F.R. § 2.12 (c)(4)); and to outside auditors, evaluators, central registries, and researchers (45 C.F.R. § 164.501, 164.506,164.512; (c); 42 C.F.R. § 2.53 (c)-(d); 42 C.F.R. § 2.52; 45 C.F.R. § 164.512(i)(1)(ii)).

ChoicePoint Health abides by Federal Confidentiality for Drug and Alcohol Treatment Regulations of 1972 (42CFR Part II). The counselor / staff, has explained the above summary to me and has
answered all my concerns regarding this program policy in a satisfactory manner. My signature below states that I understand and agree to the practice and consider myself informed. I understand that I can ask for a copy of this summary.

HIPAA

Notice Of Privacy Practices Health Insurance Portability And Accountability Act

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.

Introduction

We at ChoicePoint Health understand that health information about you and the care you receive is personal. We are committed to and are required by law to maintain the privacy of your health information. This notice applies to all records of your care maintained by us and we will abide by the terms of this Notice for as long as it is in effect.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information we maintain about you and a brief description of how you may exercise these rights.

How We Will Use and Disclose Your Health Information:

We will use and disclose your health information as described in each category listed below. We will provide a general explanation of each category; however, this is not meant to describe all
specific uses or disclosures of health information.

A. Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object

1. Treatment

We may use your health information to provide you with medical treatment or services. We may disclose information about you to physicians, nurses, technicians, health care trainees, or other personnel who are involved in caring for you. For example, our psychiatrist may consider your blood pressure before prescribing certain medications for you. Different departments within ChoicePoint Health may share medical information about you to coordinate care at treatment team meetings.

2. Treatment

We may use and disclose health information about you so treatment and services you receive may be billed and payment collected from you, an insurance company or a third party involved in the payment of your medical bills. For example, we may disclose protected health information to your insurer or the third party responsible for payment of your care for the following activities: making a determination of eligibility or coverage for health insurance; reviewing your services to determine if they were medically necessary, which may include copies or excerpts of your medical records; reviewing your services to determine if they were appropriately authorized or certified in advance of your care; reviewing your services for purposes of utilization review (to ensure the appropriateness of your care)

3. Health Care Operations

We may use and disclose health information about you for health care operations. Your health information may be used and disclosed for activities including quality assurance, utilization review,
medical review, internal auditing, accreditation, social services certification, licensing or credentialing activities, medical research, and education purposes. These disclosures are necessary to run
the organization and make sure that all consumers receive quality care. For example, we may use health information to review our treatment and services and to evaluate performance of staff. We may also disclose information to physicians, nurses, technicians, medical students, and other personnel for review and learning purposes.

4. Appointment Reminders

We may use and disclose limited health information (such as your name, address, and telephone number) to contact you as a reminder that you have an appointment for treatment or medical
care.

5. Treatment Alternatives

We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

6. Health Related Benefits and Services

We may use or disclose health information to tell you about health-related benefits or services that may be of interest to you.

7. To Another Health Care Provider

We may use or disclose health information about you to another health care provider that may treat you and/or receive payment for services provided to you. For example, we may share your health information with a hospital where you will be receiving treatment.

8. Business Associates

We may use or disclose information about you to entities assisting us in providing services related to treatment, payment, or health care operations. We are required to have a Business Associate Contract in place with all entities with which we will share your protected health information.

9. De-Identified Data/Limited Data Sets

We may use or disclose health information about you if we remove all information that could be used to identify you (what is known as "de-identified" information). We may also use or disclose a limited amount of health information about you (a "limited data set") for the purposes of research, public health, or health care operations if we enter into a data use agreement with the recipient of
the data.

10. Emergencies

We may use and disclose your health information in an emergency treatment situation. For example, we may provide your health information to a paramedic who is transporting you in an
ambulance.

11. Research

We may disclose your health information to researchers when their research has been approved by an Institutional Review Board or a similar privacy board that has waived the individual authorization requirement in accordance with the regulations covering this area.

12. As Required by Law

We will disclose health information about you when required to do so by federal or state law.

13. To Avert Serious Threat to Health or Safety

We may use and disclose health information about you to prevent a serious and imminent threat to your health or safety or to the health or safety of the public or another person.

14. Organ and Tissue Donation

If you are an organ donor, we may use or disclose your health information to an organ procurement organization or to an entity that conducts organ, eye or tissue transplantation, or serves as an organ donation bank, as necessary to facilitate organ, eye or tissue donation and transplantation.

15. Public Health Risk

We may disclose your health information for public health activities involved in preventing or controlling disease, injury, or disability. For example, we are required by state law to report the existence of communicable disease, such as acquired immune deficiency syndrome ("AIDS"), to the New Jersey State Department of Health and Senior Services to protect the health and wellbeing of the public. Other activities disclosed include the following:

• To prevent or control disease, injury, or disability;
• To report births and deaths;
• To report child abuse and neglect;
• To report reactions to medication or problems with products;
• To notify a person who may have been exposed to a communicable disease or may be at risk for contraction or spreading of a disease or condition;
• To notify the appropriate governmental authority if we believe a consumer has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when
required or authorized by law.

16. Health Oversight Activities

We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights.

17. Law Enforcement

We may release medical information if asked to do so by a law enforcement official:

• In response to a court order;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct at our facility;
• In emergency circumstances to report a crime; the location of a crime or victims; or identity, description or location of the person who committed the crime.

18. Coroners, Medical Examiners and Funeral Directors

We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release
health information about consumers to funeral directors as necessary to carry out duties.

19. Disclosures in Legal Proceedings

We may disclose health information about you to a court or administrative agency when a judge or administrative agency orders us to do so.

20. Military and Veterans

If you are a member of the armed forces, we may disclose your health information as required by military command authorities. We may also disclose your health information to determine your eligibility for benefits provided by the Department of Veterans Affairs. If you are a member of a foreign military service, we may disclose your health information to that foreign military authority.

21. National Security and Protective Services for the President and Others

We may disclose health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We may also disclose
health information about you to authorized federal officials, so they may provide protection to the President, other authorized persons, or foreign heads of state or, so they may conduct special
investigations.

22. Inmates

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement
official.

23. Workers' Compensation

We may disclose health information about you to comply with state's Workers' Compensation Law.

24. Employers

We may disclose health information about you to your employer if your health care is part of an evaluation relating to medical surveillance of the workplace, or to evaluate whether you have a work-related illness or

B. Uses and Disclosures That May Be Made Without Your Authorization, But For Which You Will Have An Opportunity To Object

1. Facility Directory

It is the policy of ChoicePoint Health Behavioral Health not to provide confirmation of names of consumers being treated by our facilities except to persons involved in your care (see below).

2. Persons Involved In Your Care

Unless you object, we may release health information about you to someone, including a family member, legal guardian, or caregiver, who is involved in your medical care or payment of your
medical care.

3. Disaster Relief

Unless you object, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

C. Uses and Disclosures of Your Health Information With Your Written Authorization

1. Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission, called an "authorization". If you provide us
permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you. You understand that we are unable to take back any records of the medical care that we have provided to you.

D. Your Rights Regarding Your Health Information

1. Right to Inspect and Copy

You have the right to request an opportunity to inspect or obtain a copy of health information in our possession. Usually, this will include clinical and billing records. You must submit your request in
writing. If you request a copy of the information, we may charge a fee for the cost of copying, mailing, and supplies associated with complying with your request. We may deny your request to inspect or obtain a copy of your health information in certain limited circumstances. In some cases, you will have the right to have the denial reviewed by another health care professional chosen
by us and who was not directly included in the original decision to deny access. If you are denied access, we will inform you in writing if the denial of your request may be reviewed. If it is reviewable and you request a review in writing, when the review is completed, we will comply with the outcome of the review.

2. Right to Amend

For as long as we keep records about you, you have the right to request us to amend any health information used to make decisions about your care or payment for your care. To request an amendment, your request must be in writing, and must explain why you believe the information is incorrect or inaccurate. We may deny your request under certain circumstances. If we deny your
request to amend, we will send you a written notice of the denial stating the basis for the denial and offering you the opportunity to provide a written statement disagreeing with the denial. If you do not wish to prepare a written statement of disagreement, you may ask that the requested amendment and our denial be attached to all future disclosures of the health information that is the subject of your request. If you choose to submit a written statement of disagreement, we have the right to prepare a written rebuttal to your statement of disagreement. In this case, we will attach the written request and the rebuttal (as well as the original request) to all future disclosures of the health information that is the subject of your request.

3. Right to an Accounting 

You have the right to request that we provide you with an accounting of list of disclosures we have made of your health information. This list will not include disclosures of your health information made for treatment, payment, or health care operations, made to you, or made as a result of an authorization signed by you. To request an accounting of disclosures, you must submit your request.

in writing. The request should state the time period for which you wish to receive an accounting. This time period should not be longer than six (6) years and not included dates before April 14,
2003 The first accounting you request within a twelve (12) month period will be free. For additional requests during the same twelve (12) month period, we will charge you for costs of the accounting. We will notify you of the amount we will charge, and you may choose to withdraw or modify your request before we incur any costs.

4. Right to Request Restrictions

You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. We are not required to agree to your
request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must inform us at a time of registration or in writing.

5. Right to Request Confidential Communications

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, or at a specified telephone number. To request confidential communications, you must notify us at the time of registration or in writing. We will not ask you the reason for the request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

6. Right to a Paper Copy of This Notice

You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time.

E. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the United States Department of Health and Human Services. To file a complaint with us, contact the Director of Substance Abuse Counseling Services, ChoicePoint Health 58 Brown Avenue, Springfield, New Jersey, 07018.

F. Changes to This Notice

We reserve the right to change the terms of our Notice of Privacy Practices. We also reserve the right to make the revised or changed Notice of Privacy Practices effective for all health information we already have about you as well as any health information we receive in the future. We will post a copy of the current Notice of Privacy Practices at all of our locations where we provide care.
You may obtain a copy of our Current Notice of Privacy Practices by requesting a copy be sent to you, or by asking for one any time you are at our office.

G. Who Will Follow This Notice

This Notice of Privacy Practices will be followed by all of ChoicePoint Health Behavioral Health staff.

ChoicePoint Health abides by Federal Health Insurance Portability and Accountability Act 1 196 (HIPAA) of 1996. The counselor / staff has explained the above summary to me and has answered all my concerns regarding this program policy in a satisfactory manner. My signature below states that I understand and agree to the practice and consider myself informed. I understand that I can ask for a copy of this summary.

NEW JERSEY SUBSTANCE ABUSE MONITORING SYSTEM (NJSAMS) RELEASE

The confidentiality of consumer / client records is maintained by this agency. This agency utilizes the New Jersey Substance Abuse Monitoring System (NJSAMS) as a participating agency involved in the D.A.S. (Division of Addiction Services).

The information entered into NJSAMS does not identify the client's name and utilizes a unique identifying number that is assigned to the client from processing of the client's information. I understand that some data or demographic information may be utilized by NJSAMS to provide data or reporting information.

I understand my
name will always remain confidential.

I understand declining to give this permission, may delay my admittance into program.

Client Rights

As a client at ChoicePoint, you have the following rights, none of which shall be abridged by the client or any of its staff, under New Jersey state law and regulations.

1. To receive the care the center is required to provide under rules adopted by the Department of Human Services Division of mental health and Addiction Services.

2. To treatment and medical services without discrimination based on race, age, religion natural origin, sex, sexual preferences, handicap, diagnosis, ability to pay, or source of payment

3. To retain and exercise fully, all the constitutional, civil, and legal rights to which the client is entitled and the center’s personnel

4. To be informed of the names and functions of all staff providing care to the client. Staff is required to identify themselves.
5. To receive, as soon as possible, the services of a translator or interpreter to facilitate communication between the client and the center's personnel.

6. To receive from the client’s counselor, in terms the client understands, an understanding of his or her complete condition, specific details about the recommended treatment and risk(s) of the
treatment. If this information would be detrimental to the client's health or if the client is not capable of understanding the information, the explanation shall be provided to his or her next-of-kin or
guardian and documented in a client record.

7. To give informed, written consent prior to the start of therapy, only after a staff member has explained in terms the client understands, specific details about the recommended procedure or
treatment, the risks involved, the possible duration of the incapacitation, and any reasonable alternatives for care and treatment.

8. To refuse substance abuse treatment after possible consequences of this decision have been explained in terms the client understands, except in life-threatening situations and instances when
treatment is required by law.

9. To be included in experimental research only when he or she gives informed, written consent to such participation or when a guardian provides such consent for an incompetent client in accordance with the law and regulation. The client may refuse to participate in experimental research, including the investigations of new therapies and medical processes.

10. Be informed if the center has authorized health care and educational institutions to participate in the client's treatment. The client also shall have the right to know the identity and functions of these institutions and may refuse to allow their participation and clients treatment.

11. To be informed of the center's policies and procedures regarding life-saving methods. Such policies and procedures shall be made available promptly in written format to the client, his or her
family or guardian, and to the public upon request.

12. To be treated with courtesy, consideration, and respect for the client’s dignity and individuality.

13. To be free from physical and mental abuse.

14. To be free from restraints unless they are authorized by a physician for a limited period to protect the client or others from injury.

15. To confidential treatment of information about the client. Information in the client's records shall not be released to anyone outside the center without approval, unless there is a signed release
of information required and permitted.

16. To receive a copy of the center's payment rates, regardless of source of payment. Upon request, the client or responsible party shall be provided with an itemized bill and an explanation of the charges if there are further questions. The client or responsible party has a right to appeal the charges. The center shall provide the client or responsible party with an explanation of procedures to
follow in making such an appeal.

17. To be advised in writing of the centers rules and regulations that applies to the conduct of clients and visitors.

18. To have prompt access to the information contained in the client's medical record, unless the program director prohibits such access, citing that to do so, it would be detrimental to the client's
treatment, and explains the reason in the record. In that instance, the clients next of kin or Guardian shall have the right to see the record. The right continues after the client is discharged from the
center for as long as the center has a copy of the record.

20. To be given a summary of these client rights, as approved by ChoicePoint Health and any additional policies and procedures established by the center involving client rights and responsibilities. This summary shall also include the name and phone number of the center staff member to whom client complain about possible rights violations Michele Reid, Program Director,
(973) 367-2500 ext. 35).

21. In addition, a summary of these client rights, as approved by ChoicePoint shall be posted conspicuously in public places throughout the center.

22. To present his or her grievances to the center’s staff member designated by the center to respond to questions or grievances about client rights and to receive an answer to these grievances
within a reasonable period.

23. The center is required to provide each client or Guardian with the names, addresses, and telephone numbers of the government agencies to which the client can complain and ask questions, including the New Jersey Department of Health Complaint Hotline at 1-877-712-1868.

24. To be advised that if they are indigent or lack the ability to pay, they may be eligible for coverage in a negotiated manner.

25. To receive information and other assistance needed to qualify and file for benefits or reimbursement.

I have been given a written copy of the "Client Rights" and given a verbal explanation of these rights, in terms that I could understand.

I have been made aware of the policy regarding the "Grievance Procedure" and was shown were it is posted in the waiting room area of the facility.

ACKNOWLEDGEMENT OF CADC COUNSELOR / INTERN

I have been informed that some of the services received at ChoicePoint Health may be performed by a CADC, LAC, LSW or LCADC counselor / intern. I am aware the counselor intern receives
regular supervision by a Licensed Professional or Clinical Supervisor.

ChoicePoint Health abides by N.J.A.C. 10:161B Standards for Clinical Supervision. The counselor / staff has explained the above statement to me in terms I can understand and has answered all
my concerns regarding this policy.

My signature below states that I understand and agree to the practice, consider myself informed, and hereby give written consent to comply with the use of counseling interns.

Consent For Pregnancy Test

It is the policy of ChoicePoint to have female clients evaluated to determine the necessity of a pregnancy test.

PROCEDURE:

1. Upon admission, clients must provide a medical exam, completed 7 days prior to or within 2 days of admission.
2. The Physical Exam will include the need for female clients to be evaluated for the necessity of a pregnancy test.
3. Clients deemed in need of a pregnancy test will self-administer a pregnancy test with the supervision of staff. Results will be noted in the clinical record.
4. Results of the tests will be documented in the medical section of the file and co- signed by the physician.
5. Positive Pregnancy Test: If a client is found to be pregnant, an immediate medical conference will be held with the clinical staff, client and significant others within 24 hours.
6. Client will be referred to case management services for referral and linkage for proper medical care or referred to an inpatient detoxification program.

Consent for Reporting Communicable Diseases

I hereby give my permission to release to the New Jersey Department of Health, Disease Control Division any information regarding the below:

New Jersey Statutes provide that any attending practitioner licensed in New Jersey to practice medicine who diagnoses or suspects the existence of a communicable disease among humans or
from animals to humans shall immediately report that fact to the Department of Public Health.

The Public Health Unit serves as the department's representative in this reporting requirement. Modifiable diseases or conditions which are to be reported within 48 hours to the County Health unit
are listed below:

By signing this document, you are acknowledging your receipt and full understanding of the information provided.

Universal Precautions For Infection Control

Universal Precautions refer to the usual and ordinary steps you need to take in order to reduce the risk of infectious disease such as HIV or Hepatitis C.

The prevention of transmission of infectious diseases is based on the avoidance of skin and mucous membrane contact with blood and other body fluids.
AVOID UNNECESSARY RISKS

-If a fellow patient or client needs assistance, please call a staff member immediately.
-When avoidable, don’t expose yourself to other person’s blood or body fluids.
-Never share needles, razors or any other personal sharp objects.
-Always call on trained individuals to clean up blood or other body fluid spills.

PROTECT YOURSELF

-Use barrier protection to prevent skin and mucous membrane contact with blood and other body fluids.
-Wear gloves to prevent contact with blood, infectious materials, or other potentially contaminated surfaces or items.
-Wear face protection if blood or body fluid droplets may be generated during a procedure.
-Wear protective clothing if blood or body fluids may be splashed during a procedure.
-Wash hands and skin immediately and thoroughly if contaminated with blood or body fluids.
-Wash hands immediately after gloves are removed.
-Use care when handling sharp instruments and needles. Place used sharps in labeled, puncture resistant containers.
-If you have sustained and exposure or puncture wound, immediately flush the exposed area and notify a staff member.

RESPIRATORY HYGIENE/COUGH ETIQUETTE:

Respiratory Hygiene/Cough Etiquette is an important element of Standard Precautions. As a result, ChoicePoint has implemented various mechanisms and tools in an attempt to educate and inform patients, volunteers, and staff. Throughout the main areas, group rooms, kitchen, offices and all bathrooms we have placed informative/education based laminate signs that promote Cough
Etiquette.

Additionally, non-alcohol based hand sanitizers have been placed throughout the facility to ensure cleanliness of hands after a possible sneeze or cough. Further, paper towels/napkins in close proximity to trash receptacles are also located throughout the facility to cough or sneeze into.

HANDWASHING

Following safe hand washing practices is important in ChoicePoint. The goal in our organization is to improve hand hygiene compliance amongst staff and patients. Hand washing can lessen the ability to transmit disease like the common cold and the flu, along with more serious illnesses, which is important with the population we serve. Presently, signs are posted in the bathrooms on hand washing and all employees are educated on the company policy regarding hand washing. Hand sanitizers are provided for staff, and in areas that can be safely supervised by staff. They are especially encouraged to used be in cold and flu season. Frequently used equipment such as telephones, computer keyboards and similar items are breeding grounds for bacteria. Our goal is to limit exposure and follow basic hygiene practices and improve staff and patient compliance with hand washing. By improving Handwashing, limits the exposure to airborne illnesses such as but
not limited to, influenza.

Protecting yourself from HIV

• Avoid risky behavior
• Protect yourself from sharp injuries
• Wear gloves when in contact with body fluids if possible
• Wear mask and eye protection when splash injuries are possible
• Call on trained individuals to clean up blood spills

Consent For Drug Screening

It is the policy of ChoicePoint to provide each client with an alcohol- and illicit drug-free environment. Urine and oral drug screens and breathalyzer tests will help us in achieving this goal.

As a client of ChoicePoint Health, I understand I will be expected to submit a sample for drug and/or alcohol screening under the supervision of staff.

Consent for Tuberculosis Skin Test

Consent TB and HIV Testing

Standards for Licensure of Outpatient Substance Abuse Treatment Facilities 10:161B-6.2 Client Care Policies and Procedures (a) state that client care policies shall; "9. Care of clients with
tuberculosis, which is not transmissible. or no longer communicable"

Also, Appendix A states.

1. All clients will receive TB counseling and education before admission to a Substance Abuse Treatment Facility (SATF).
2. Clients will receive a symptom assessment for pulmonary tuberculosis before admission to a SATF. History of treatment for TB disease, tuberculin tests (TST) or adequate treatment for latent TB infection (LTBI) will be obtained. An efficient and feasible screening tool to identify those persons in need of evaluation for active tuberculosis. Disease attending SATFs is the implementation of a Pulmonary Tuberculosis Symptom Assessment.

3. All clients with symptoms consistent with pulmonary tuberculosis will promptly be referred for a chest X-ray and medical evaluation for active tuberculosis.

If you are interested in TB and / or HIV testing, please make an appointment with your primary care physician. If you do not have a primary care physician, the following may be able to provide
these services for you.

Med-Express Urgent Care
184 Essex St, Lodi, NJ, 07644
(201) 843-3207

Bergen County Department of Health Services Health Counseling Center
120 South River Street, Hackensack, NJ 07601 (201) 336-3350

It is the policy of ChoicePoint that the Client photograph is for therapeutic purposes and will be conducted upon consent of the Client and only with approved equipment.

Photographs taken of me or parts of my body can be used solely for the purpose of medical care with ChoicePoint. The photos and all details will be kept confidential within my personal medical
record at ChoicePoint.

TELEHEALTH INFORMED CONSENT

Telehealth is healthcare provided by electronic devices such as phones, computers, and cellphones. In telehealth services, medical and mental health information is used for diagnosis,
consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through HIPAA Compliant Electronic Communications. Telephone
consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature with the opportunity to have questions answered to my satisfaction.

Program Rules & Guidelines

PROGRAM RULES

1. No threatening, yelling, or cursing.
2. Always treat others with respect.
3. If upset or frustrated, please talk to staff person.
4. If offended in group please see Program Director: Michele Reid or Assistant Director. If Directors are unavailable please wait for their return in lobbies with seating, while under supervision of
staff members not facilitating group.
5. Do not make fun of, single out, or intentionally offend another group member or staff member.
6. Put forth efforts to work as a cohesive group by providing productive feedback.
7. Make every effort to stay awake during Groups. Inability to stay away may result in discharge from program.
8. If requested by facilitator, raise hand and wait to be called on in Groups. Do not interrupt other group members.
9. Due to possible violations of HIPAA and other confidentiality policies, cell phones must be turned off during group.
10. Participate and be open to scheduled activities and interventions. If there is a need to be excused, please inform Group Facilitator.

11. If a consumer needs to lie down due to illness, written permission from Case Manager is needed. If Case Manager is not available, get a note from a Supervisor or Nurse.
12. No stealing.
13. Maintain personal hygiene out of respect for other consumers.
14. No sexually provocative or inappropriate clothing, including low cut or short shirts or skirts, saggy pants, where skin or undergarments are showing.
15. Smoke breaks are according to schedule. Smoking is only permitted outside in designated smoking areas on designated smoke breaks.
16. No smoking in bathroom or any other areas of building.
17. When you are finished eating or doing an activity, clean up after yourself.
18. Wash hands before lunch and after using the bathroom.
19. Before leaving building, you must notify staff. Failure to do so may result in discharge from program.

20. No selling of items or bartering. Financial gain or profit, giving or accepting / receiving items without staff permission may result in immediate discharge. No borrowing. lending, giving or
accepting of money or other items from others.
21. Due to health concerns do not share cigarettes.
22. No saving of seats. Seats are not assigned and on a first come basis.
23. Stay seated during meals.
24. No eating of food during Groups or in areas not designated for eating.
25. If you need to use the telephone, please get a note from your Case Manager during break. The telephone should only be used for important matters. 26. Do not bring valuables or large
amounts of money to Program. Staff is not allowed to store or handle valuable and ChoicePoint is not responsible for lost, stolen, or misplaced items.
27. Do not bring bags to group.
28. Do not leave group excessively, as deemed by facilitator.
30. Only wear sunglasses and hats outdoors.
31. Keep the bathrooms neat by cleaning up after yourself. If you see someone else makes a mess, tell Program Director or Assistant Program Director (Supervisor) privately.
32. If you are late to program, you will need to get a note from your Case Manager, Program Director, or Assistant Program Director (Supervisor).
33. Attend the Groups in which you are scheduled. If you want or require a change in groups you need get approval from your Case Manager, Assistant Program Director, Supervisor, or Program
Director.
34. Do not make physical contact with other group members during program hours i.e. hugging or kissing.
No Physical Violence, threats of harm. yelling, or swearing is allowed. You will be automatically suspended from Program and pending possible discharge. For smaller infractions of the rules.
If you fight with or assault another person, group member, or staff member you will be immediately terminated from program.

Orientation

Upon admission, I was provided an orientation and given a copy of the client handbook that included each of the following:

GRIEVANCE PROCESS/ ADVOCACY INFORMATION

Questions related to decisions made by your case manager, counselor or other staff concerning service delivery, or the denial, or termination of services are appropriate subjects for by the ombudsperson. Any consumer, applicant, or person that has been a consumer within the last three (3) months or his/her designee, parent, or guardian shall have the right to seek review.

Complaints shall be directed to the Director of Substance Abuse Services, who will investigate your complaint within five (5) business days and negotiate a resolution with you. A written report of the findings and suggested resolution of the complaint report will be maintained on file at ChoicePoint Health. Upon a request, a written complaint can be provided to you, in addition, you may
contact any of the listed agencies below for guidance and / or advocacy available to you.

GRIEVANCE PROCESS

A Grievance is a written or verbal expression of dissatisfaction of services, actions, lack of actions, or manner of treatment by ChoicePoint Health or its staff affecting an individual.

If you would like to file a grievance regarding an incident occurring while in treatment at ChoicePoint Health, please follow this procedure. Our goal is to provide an environment of respect and dignity and to always work in cooperation with our clients and their families.

STEPS TO THE PROCEDURE:

Note: There is an internal and external procedure. The internal procedure involves contacting the Director of Substance Abuse Counseling Service: Michele Reid

Questions related to decisions made by your case manager, counselor or other staff concerning service delivery, or the denial, or termination of services are appropriate subjects for by the ombudsperson. Any consumer, applicant, or person that has been a consumer within the last three (3) months or his/her designee, parent, or guardian shall have the right to seek review.

Complaints shall be directed to the Director of Substance Abuse Services, who will investigate your complaint within five (5) business days and negotiate a resolution with you. A written report of the findings and suggested resolution of the complaint report will be maintained on file at ChoicePoint Health.

Upon a request, a written complaint can be provided to you, In addition, you may
contact any of the listed agencies below for guidance and / or advocacy available to you.

THE EXTERNAL PROCESS INVOLVES CONTACTING THE:

New Jersey State Department of Human Services

Division of Addiction Services
P.O. Box 362, Trenton, New Jersey 08625-0362 Telephone: Toll-free 1-877-712-1868

Welcome: We are a treatment program for those who seek recovery from substance use disorders and/or mental health problems. It is our aim to provide you with a safe, secure, supportive environment and an array of professional services, activities and experiences that will assist you in achieving success in your journey.

We see our relationship with you as a partnership for your benefit and our work together as moving toward a positive change.

About ChoicePoint

We are very happy that you have chosen to receive services with us. We will do everything we can to help you reach your goals as quickly as possible. In order to do that, we have a special way
of working with our clients, guided by some core values, beliefs and ideas. The services are based upon an approach that is client centered and results driven. We work very hard to form partnerships with the people we serve, so that each individual and/or family can overcome their current and future challenges and resume successful productive lives.

We have adopted the core values of safety/security, partnership, respect, accountability and positive change. We will behave according to these values in our partnership; we also believe that
when you treat yourself and others in the same value-guided way, you have the greatest opportunities for success.

Your perceptions of a working relationship and your progress with us are of critical importance. Change depends on using your ideas and abilities more than anything else.

If you are not getting what you need, please talk with staff. The staff is in the best position to change how they are working with you to help you get what you need.

Mission Statement CHOICEPOINT’s driving principle, which informs all our work, is that clients should be empowered to make an informed choice about their individual journey to recovery.

We embrace both a Medication Assisted and Abstinence approach to the treatment of addiction. CHOICEPOINT understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence and acknowledges that some ways of using drugs are clearly safer than others.

Our mission is to provide high quality, outcome focused drug and alcohol addiction recovery services that empower individuals to attain a lifestyle characterized by independence, personal health
and citizenship.

We are committed to supporting, educating and enriching, through collaboration, training and leadership, the communities we serve and championing addiction recovery.

Summary We hope this packet will be of good use to you as you embark on your treatment journey. We have identified several areas in your packet that we feel will be of importance for you to work on in addition to the clinical services you will be receiving. Your input into these areas is actively sought since this is your treatment and you have an active voice in your treatment plan. Completion of your treatment is not an end. It is a completion of a particular phase of your overall recovery process. We are here to help you in any way we can. Help is a two-way street. You need to do your part and be an active participant in your journey, which includes following the structure and regulations of the facility.

CHOICEPOINT, along with the staff, want to again welcome you as you embark on your treatment journey. We hope you will embrace the core values of the approach which are:

1) Safety/Security
2) Partnership
3) Respect
4) Accountability
5) Positive Change

In addition, being accountable for keeping all scheduled appointments, adhering to the structure of the Program, establishing positive support systems through partnerships with staff and peers,
and respecting your environment will allow the change process to begin. Once again, welcome to CHOICEPOINT, we will strive to be your partner throughout this process so you can make the choices that will serve you well in your life.

Mailing address and Contact Information for the Main Office is:

23-00 Route 208, Suite 2-9 Fair Lawn NJ 07410

Length of Stay: The length of your treatment is individually determined based upon our clinical assessment and recommendations as well as in accord with what you are able to afford.

If the cost of your treatment is being paid by your insurance company please be aware that they often have rules and restrictions on length of stay, allowable services and level of care. Failure to follow their guidelines may result in non-payment in which case you would be responsible for the cost of services rendered. You may need to work out an alternate arrangement for payment. If so,
please contact the business office as soon as possible.

Orientation: Your first few days in treatment will be considered an orientation to the program. You will be introduced to staff and assigned a primary therapist. You will have an initial treatment plan with some goals and tasks to work on. You will be attending sessions as agreed upon in the assessment and planning process. Please feel free to ask any staff member questions if you need
assistance with anything. We want you to get settled into your program as soon as possible.

Services will include the some or all of the following:

• Individual, group, couples and family therapy with clinical staff
• Weekly sessions with your Primary Therapist
• HIV/AIDS education
• Spiritual Counseling
• Medication Management and Psychiatric Assessment, if indicated
• Job Readiness Participation and Internet Job Searches
• Job Applications/Resumes and Coaching for Job Interviews
• Life Skills Programs
• Case Management
• Housing assistance (if available)

• Random UA/breathalyzer tests
• Discharge and Aftercare planning
• Pre-admission consultation with a licensed professional therapist

Transportation: We do not currently offer transportation, but have the availability to arrange transport clients to appointments if pre-approved. If clients have their own cars, they may use them as long as you have a valid driver’s license.

We discourage you from transporting other clients to and from treatment unless pre-approved by staff. We also have access to low-cost bus passes for those who qualify and need to take the bus to get around. All services with the exception of outpatient detox may be conducted remotely via telehealth if applicable, therefore eliminating the need for transportation.

ACCESS TO INFORMATION AND PRIVACY LAWS:

All information about you and the services you receive here are confidential and private under federal and state laws. We will fully protect your privacy and confidentiality of the law. Family or significant others may participate in your treatment and have access to your information but only with your written authorization. All of your rights regarding confidentiality and the limits of the law
are explained in the Notice of Privacy Practices posted throughout the facility and contained in this handbook below.

LEVELS OF CARE & CLIENT TREATMENT JOURNEY

LEVELS OF CARE

● Outpatient Detox
● Medication Assisted Treatment (MAT)
● Intensive Outpatient
● Outpatient
● Co-Occurring

Admissions and Scheduling

1. You will conduct a drug and alcohol pre-screen assessment with our admissions team.
2. Our admissions team will verify any insurance coverage or discuss cash-pay options with you.
3. You will be sent electronically ChoicePoint’s New Client Registration.
4. You will be scheduled for your first appointment once the documentation is completed. Remote patients will be set up for their remote-drug testing compliance program.
5. Medication insurance coverage is dependent on specific benefits. If a co-pay or any other patient responsibility for medications is required, please ensure to bring cash or a credit card for payment, as we are not allowed legally to pay for your medications.

Clinical Intake
1. You will meet with a member of the clinical staff (virtually) for an intake assessment to learn more about you and build a custom-tailored treatment program to maximize your long-term

success.

2. From here it will be determined the appropriate level of care and treatment program.

ChoicePoint offers different levels of care such as:

a. Outpatient/Ambulatory Detox with extended on-site medical monitoring.
b. Medication Assisted Treatment (Suboxone, Vivitrol)
c. Intensive Outpatient
d. Outpatient
e. Co-Occurring (Substance use alongside other mental-health items)

Outpatient Detox

(If not entering detox level of care, skip to appropriate level of care)

1. Detoxes on average take 3-10 days and are entirely customized based on factors such as substance of use, amount, and duration of time.

2. We recommend packing a lunch for each outpatient detox day, or just as common, clients will utilize delivery services such as DoorDash and Uber Eats.

3. Outpatient detox days can range from around 4-6 hours a day depending on medical necessity.

4. We recommend having transportation to and from the facility during these days, as a safety precaution.

Medication-Assisted Treatment (MAT)

(In-Person or Virtual)

1. On your first visit you will conduct a Nursing Assessment with our Nursing Team which will assess symptoms and assessment scores, and any necessary labs needed.

2. You will then meet with our seasoned addiction Physicians and assess your medication-assisted treatment plan and order any necessary medications. Medications can be delivered to your
home or picked up from your local pharmacy.

3. You will meet with your Navigator who will help you set up appointments, recovery planning, and any additional support.

4. You will meet weekly with your Physician for the first 4-6 weeks on average for Stabilization. Visits can last from 15 minutes-1 hour depending on severity or

5. Symptoms.
6. For the first 6 weeks you will also meet weekly with your Navigator who will continue to help you navigate your recovery journey. These usually average around 15 minutes a week.

7. After you have been successfully stabilized on your MAT medication you will move into the maintenance phase.

8. All MAT clients are required to participate in clinical services as part of their treatment to greatly increase your chances of long-term recovery compared to medication alone.

Intensive Outpatient

(In-Person or Virtual)

1. IOP is a clinical program that puts the client on the best path for success, it includes:
a. Individual counseling where you will meet with your counselor weekly.
b. Group Therapy ranges from three to five times a week, depending on your

2. treatment plan, and averages three hours.

3. c. Support Sessions with those involved in your treatment to provide optimal success.

Outpatient

(In-Person or Virtual)

1. OP is a step-down level from IOP and provides a less intensive step in your long-term recovery. It includes:
a. Individual counseling once a month.
b. Group therapy once per week for three hours
c. Support Sessions with those involved in your treatment to provide optimal success.

CHOICEPOINT
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. This information about you that may identify you and that relates to your past, present or future physical or mental
health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in
accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules,
and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this
Notice of Privacy Practices. We reserve 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 PHI that we
maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one
to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related
services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment: We may use and disclose PHI 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
PHI necessary for purposes of collection.

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

Required by Law: Under the law, we must disclose your PHI 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.

Without Authorization: Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose
information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without
an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA. Child Abuse or Neglect: We may disclose your PHI to a
state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings: We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients: We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to
death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as
next-of-kin. The PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies: We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of
this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care: We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight: If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this
information include government agencies and organizations that provide financial assistance to the program (such as third-party payers based on your prior consent) and peer review organizations
performing utilization and quality control.

Law Enforcement: We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar
document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the
reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions: We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national
security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the
need to prevent serious harm.

Public Health: If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety: We may disclose your PHI if 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.

Research: PHI may only be disclosed after a special approval process or with your authorization. Fundraising: We may send you fundraising communications at one time or another. You have the
right to opt out of such fundraising communications with each solicitation you receive.

Verbal Permission: We may also 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 at any time, except to the extent
that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures
of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii)
disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at CHOICEPOINT:

● Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record
set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be
restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes.
We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of
your PHI be provided to another person

● Right to Amend: If you feel that the PHI 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. If
we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact
the Privacy Officer if you have any questions.

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

● Right to Request Restrictions: You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not
required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health
care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

● Right to Request Confidential Communication: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will
accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for
accommodating your request. We will not ask you for an explanation of why you are making the request.

● Breach Notification: If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

● Right to a Copy of this Notice: You have the right to a copy of this notice.

FS Chapter 397.501 – Rights of Individuals

Individuals receiving substance abuse services from any service provider are guaranteed protection of the rights specified in this section, unless otherwise expressly provided, and service
providers must ensure the protection of such rights.

(1) RIGHT TO INDIVIDUAL DIGNITY. —The dignity of the individual served must be respected at all times and upon all occasions, including any occasion when the individual is admitted,
retained, or transported. Individuals served who are not accused of a crime or delinquent act may not be detained or incarcerated in jails, detention centers, or training schools of the state, except
for purposes of protective custody in strict accordance with this chapter. An individual may not be deprived of any constitutional right.

(2) RIGHT TO NONDISCRIMINATORY SERVICES. —
(a) Service providers may not deny an individual access to substance abuse services solely on the basis of race, gender, ethnicity, age, sexual preference, human immunodeficiency virus status,
prior service departures against medical advice, disability, or number of relapse episodes. Service providers may not deny an individual who takes medication prescribed by a physician access to
substance abuse services solely on that basis. Service providers who receive state funds to provide substance abuse services may not, if space and sufficient state resources are available, deny
access to services based solely on inability to pay.

(b) Each individual in treatment must be afforded the opportunity to participate in the formulation and periodic review of his or her individualized treatment or service plan to the extent of his or her
ability to so participate.

(c) It is the policy of the state to use the least restrictive and most appropriate services available, based on the needs and the best interests of the individual and consistent with optimum care of
the individual.

(d) Each individual must be afforded the opportunity to participate in activities designed to enhance self-image.

(3) RIGHT TO QUALITY SERVICES. —

(a) Each individual must be delivered services suited to his or her needs, administered skillfully, safely, humanely, with full respect for his or her dignity and personal integrity, and in accordance
with all statutory and regulatory requirements.

(b) These services must include the use of methods and techniques to control aggressive behavior that poses an immediate threat to the individual or to other persons. Such methods and
techniques include the use of restraints, the use of seclusion, the use of time-out, and other behavior management techniques. When authorized, these methods and techniques may be applied
only by persons who are employed by service providers and trained in the application and use of these methods and techniques. The department must specify by rule the methods that may be
used and the techniques that may be applied by service providers to control aggressive behavior and must specify by rule the physical facility requirements for seclusion rooms, including
dimensions, safety features, methods of observation, and contents.

(4) RIGHT TO COMMUNICATION. —
(a) Each individual has the right to communicate freely and privately with other persons within the limitations imposed by service provider policy.

(b) Because the delivery of services can only be effective in a substance abuse free environment, close supervision of each individual’s communications and correspondence is necessary,
particularly in the initial stages of treatment, and the service provider must therefore set reasonable rules for telephone, mail, and visitation rights, giving primary consideration to the well-being and
safety of individuals, staff, and the community. It is the duty of the service provider to inform the individual and his or her family if the family is involved at the time of admission about the provider’s
rules relating to communications and correspondence.

(5) RIGHT TO CARE AND CUSTODY OF PERSONAL EFFECTS. —An individual has the right to possess clothing and other personal effects. The service provider may take temporary custody of
the individual’s personal effects only when required for medical or safety reasons, with the reason for taking custody and a list of the personal effects recorded in the individual’s clinical record.

(6) RIGHT TO EDUCATION OF MINORS. —Each minor in a residential service component is guaranteed education and training appropriate to his or her needs. The service provider shall
coordinate with local education agencies to ensure that education and training is provided to each minor in accordance with other applicable laws and regulations and that parental responsibilities
related to such education and training are established within the provisions of such applicable laws and regulations. This chapter does not relieve any local education authority of its obligation
under law to provide a free and appropriate education to every child.

(7) RIGHT TO CONFIDENTIALITY OF INDIVIDUAL RECORDS . —
(a) The records of service providers which pertain to the identity, diagnosis, and prognosis of and service provision to any individual are confidential in accordance with this chapter and with
applicable federal confidentiality regulations and are exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. Such records may not be disclosed without the written consent of the
individual to whom they pertain except that appropriate disclosure may be made without such consent:
1. To medical personnel in a medical emergency.
2. To service provider personnel if such personnel need to know the information in order to carry out duties relating to the provision of services to an individual.
3. To the secretary of the department or the secretary’s designee, for purposes of scientific research, in accordance with federal confidentiality regulations, but only upon agreement in writing
that the individual’s CHOICEPOINT and other identifying information will not be disclosed.

4. In the course of review of service provider records by persons who are performing an audit or evaluation on behalf of any federal, state, or local government agency, or third-party payor
providing financial assistance or reimbursement to the service provider; however, reports produced as a result of such audit or evaluation may not disclose CHOICEPOINTs or other identifying
information and must be in accordance with federal confidentiality regulations.

5. Upon court order based on application showing good cause for disclosure. In determining whether there is good cause for disclosure, the court shall examine whether the public interest and
the need for disclosure outweigh the potential injury to the individual, to the service provider and the individual, and to the service provider itself.

(b) The restrictions on disclosure and use in this section do not apply to communications from provider personnel to law enforcement officers which:
1. Are directly related to an individual’s commission of a crime on the premises of the provider or against provider personnel or to a threat to commit such a crime; and
2. Are limited to the circumstances of the incident, including the status of the individual committing or threatening to commit the crime, that individual’s CHOICEPOINT and address, and that
individual’s last known whereabouts.

(c) The restrictions on disclosure and use in this section do not apply to the reporting of incidents of suspected child abuse and neglect to the appropriate state or local authorities as required by
law. However, such restrictions continue to apply to the original substance abuse records maintained by the provider, including their disclosure and use for civil or criminal proceedings which may
arise out of the report of suspected child abuse and neglect.

(d) Any answer to a request for a disclosure of individual records which is not permissible under this section or under the appropriate federal regulations must be made in a way that will not
affirmatively reveal that an identified individual has been, or is being diagnosed or treated for substance abuse. The regulations do not restrict a disclosure that an identified individual is not and
has never received services.

(e)1. Since a minor acting alone has the legal capacity to voluntarily apply for and obtain substance abuse treatment, any written consent for disclosure may be given only by the minor. This
restriction includes, but is not limited to, any disclosure of identifying information to the parent, legal guardian, or custodian of a minor for the purpose of obtaining financial reimbursement.
2. When the consent of a parent, legal guardian, or custodian is required under this chapter in order for a minor to obtain substance abuse treatment, any written consent for disclosure must be
given by both the minor and the parent, legal guardian, or custodian.

(f) An order of a court of competent jurisdiction authorizing disclosure and use of confidential information is a unique kind of court order. Its only purpose is to authorize a disclosure or use of
identifying information which would otherwise be prohibited by this section. Such an order does not compel disclosure. A subpoena or a similar legal mandate must be issued in order to compel
disclosure. This mandate may be entered at the same time as, and accompany, an authorizing court order entered under this section.

(g) An order authorizing the disclosure of an individual’s records may be applied for by any person having a legally recognized interest in the disclosure which is sought. The application may be
filed separately or as part of a pending civil action in which it appears that the individual’s records are needed to provide evidence. An application must use a fictitious CHOICEPOINT, such as
John Doe or Jane Doe, to refer to any individual and may not contain or otherwise disclose any identifying information unless the individual is the applicant or has given a written consent to
disclosure or the court has ordered the record of the proceeding sealed from public scrutiny.
(h) The individual and the person holding the records from whom disclosure is sought must be given adequate notice in a manner which will not disclose identifying information to other persons,
and an opportunity to file a written response to the application, or to appear in person, for the limited purpose of providing evidence on the statutory and regulatory criteria for the issuance of the
court order.

(i) Any oral argument, review of evidence, or hearing on the application must be held in the judge’s chambers or in some manner which ensures that identifying information is not disclosed to
anyone other than a party to the proceeding, the individual, or the person holding the record, unless the individual requests an open hearing. The proceeding may include an examination by the
judge of the records referred to in the application.

(j) A court may authorize the disclosure and use of records for the purpose of conducting a criminal investigation or prosecution of an individual only if the court finds that all of the following criteria
are met:
1. The crime involved is extremely serious, such as one which causes or directly threatens loss of life or serious bodily injury, including but not limited to homicide, sexual assault, sexual
battery, kidnapping, armed robbery, assault with a deadly weapon, and child abuse and neglect.
2. There is a reasonable likelihood that the records will disclose information of substantial value in the investigation or prosecution.
3. Other ways of obtaining the information are not available or would not be effective.
4. The potential injury to the individual, to the physician-individual relationship, and to the ability of the program to provide services to other individuals is outweighed by the public interest and
the need for the disclosure.

(8) RIGHT TO COUNSEL. —Each individual must be informed that he or she has the right to be represented by counsel in any involuntary proceeding for assessment, stabilization, or treatment
and that he or she, or if the individual is a minor his or her parent, legal guardian, or legal custodian, may apply immediately to the court to have an attorney appointed if he or she cannot afford
one.

(9) RIGHT TO HABEAS CORPUS. —At any time, and without notice, an individual involuntarily retained by a provider, or the individual’s parent, guardian, custodian, or attorney on behalf of the
individual, may petition for a writ of habeas corpus to question the cause and legality of such retention and request that the court issue a writ for the individual’s release.

(10) LIABILITY AND IMMUNITY. —

(a) Service provider personnel who violate or abuse any right or privilege of an individual under this chapter are liable for damages as determined by law.
(b) All persons acting in good faith, reasonably, and without negligence in connection with the preparation or execution of petitions, applications, certificates, or other documents or theapprehension, detention, discharge, examination, transportation, or treatment of a person under the provisions of this chapter shall be free from all liability, civil or criminal, by reason of such acts.

COMPLAINTS: If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at 23-00 Route 208 Suite 2-9, Fair Lawn NJ 07410 or with
the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

GRIEVANCES: It is the policy of CHOICEPOINT to provide the best possible services to all clients. In the event that any resident feels that the agency has not met his/her expectations, the person
may file a grievance. Clients will be advised of the grievance procedure upon entry to the facility. The client will obtain a copy of the grievance procedure, and will sign a copy for their client record.
Clients will be instructed to follow these steps in order to file a grievance:

Grievance Procedure:
1. Any person(s) who believes that their rights have been violated or has a complaint or grievance may file a complaint pursuant to the procedures set forth below, on their behalf or on the behalf
of another person. All persons are encouraged to file a grievance. By filing a complaint, the individual will not subject themselves to any form of adverse action, reprimand, retaliation, or otherwise
negative treatment by Elevations Health. Clients shall have immediate access to the grievance form; a posting of the grievance procedure will be in the group room with the levels of appeals, and
in the Patient handbook.

2. The processing procedures for grievances and complaints are as follows:
1. The Client is encouraged to discuss any problems with their therapist. The Client and therapist will try to find a resolution. The therapist will correspond with the Clinical Director on the
grievance and/or complaint and any resolution.
2. All grievances shall first be filed with the Clinical Director by completing a "Client Grievance" form. The Human Resources Director and/or Designee shall give the Client a receipt of the filed
grievance and log the grievance. The Director will conduct an internal investigation and render an initial determination and resolution within 2 days of receipt of the complaint in writing.
3. If the complainant is not satisfied or if the complaint is not resolved with the results achieved in Step 2, the complainant may file an appeal and/or the grievance shall be forwarded to the
Executive Director and this meeting shall be held within five working days of the date it is requested.
4. The Client shall be presented a resolution and response to their grievance in writing.
5. In the event that the Client does not feel a resolution has been reached they may contact DMAS and the Client Advocatory.

3. The Clinical Director and the Director shall take steps to ensure an appropriate investigation of each complaint to determine its validity. These rules contemplate informal, but thorough,
investigations affording all interested persons and their representatives, if any, an opportunity to submit evidence relevant to the complaint.

4. Any allegations of physical or sexual abuse by a therapist shall immediately be brought to the attention of the Clinical Director and the police shall be notified. The Client will be afforded the
opportunity to contact the Police, New Jersey Abuse Hotline, Department of Health and the New Jersey Disability Rights. The telephone numbers of the hotlines are posted on the Client Bulletin
Board.

INFECTION CONTROL POLICY AND PROCEDURES:
The staff is required by the State of New Jersey to assess all clients for infectious disease risk for HIV, Hepatitis, Tuberculosis, etc. All clients must be screened for certain infectious diseases upon
admission and, if in need of treatment, must adhere to the prescribed medical regimen. We ask that you notify staff if you have any communicable or infectious diseases at the present time or
during your involvement with us, which may inadvertently pose a health threat to others in a community or a group setting if not addressed. We provide education, counseling and referral services Wave!as needed. In the event that you do have an infectious disease, your rights and confidentiality will be protected to the extent of the law. CHOICEPOINT will also do its best to obtain medical care
for you. However, we are required, according to New Jersey Statute Chapter 397 F.S. and Chapter 65D-30 F.A.C., Section 381.0031 and 384.25 F.S., to report the communicable disease to
DMAS.

Here are some facts about HIV/AIDS/TB/STDs. Please read carefully. Your counselor will review the information with you and answer any questions or clarify any areas that may not be clear. This
handout is yours to take with you. You may wish to share this information with your sexual partner or other significant individuals.

WHAT IS IT?

AIDS (Acquired Immune Deficiency Syndrome) is a disease caused by a virus called HIV (Human Immunodeficiency Virus).
● When a person is infected with HIV, the virus infects and can kill certain cells in the immune system called T- helper cells. This weakens the immune system so that other opportunistic
infections can occur. The HIV-infected person is said to have AIDS when they become sick with other specific infections or when the number of T-helper cells has dropped below 200.

● There is no cure for HIV. Although people do not die from HIV, most people who become infected with HIV will eventually develop AIDS. You can have HIV for several years without showing
any signs. That means you can have HIV and not even know it. You can also spread HIV during that time to other people. As of 1996, about half of everybody that got HIV would develop AIDS
within ten years. Now, with the help of new drug treatments, the time between infection of HIV and the time it takes to develop AIDS can be even longer.

WHO CAN GET HIV/AIDS?

● People of any sex, age, and race can get HIV/AIDS. More than 1.2 million people in the United States are living with HIV infection, and almost 1 in 8 (12.8%) are unaware of their infection.
● Gay, bisexual, and other men who have sex with men (MSMa), particularly young black/African American MSM, are most seriously affected by HIV.
● By race, blacks/African Americans face the most severe burden of HIV.

CDC estimates that 1,218,400 persons aged 13 years and older are living with HIV infection, including 156,300 (12.8%) who are unaware of their infection. Over the past decade, the number of
people living with HIV has increased, while the annual number of new HIV infections has remained relatively stable. Still, the pace of new infections continues at far too high a level—particularly
among certain groups.

HIV Incidence (new infections): The estimated incidence of HIV has remained stable overall in recent years, at about 50,000 new HIV infections per year. Within the overall estimates, however,
some groups are affected more than others. MSM continue to bear the greatest burden of HIV infection, and among races/ethnicities, African Americans continue to be disproportionately affected.

HIV Diagnoses (new diagnoses, regardless of when infection occurred or stage of disease at diagnosis): In 2013, an estimated 47,352 people were diagnosed with HIV infection in the United
States. In that same year, an estimated 26,688 people were diagnosed with AIDS. Overall, an estimated 1,194,039 people in the United States have been diagnosed with AIDS.

Deaths: Deaths: An estimated 13,712 people with an AIDS diagnosis died in 2012, and approximately 658,507 people in the United States with an AIDS diagnosis have died overall. The deaths of
persons with an AIDS diagnosis can be due to any cause—that is, the death may or may not be related to AIDS.

By Risk Group
Gay, bisexual, and other men who have sex with men (MSM) of all races and ethnicities remain the population most profoundly affected by HIV.

In 2010, the estimated number of new HIV infections among MSM was 29,800, a significant 12% increase from the 26,700 new infections among MSM in 2008.

Although MSM represents about 4% of the male population in the United States, in 2010, MSM accounted for 78% of new HIV infections among males and 63% of all new infections. MSM
accounted for 54% of all people living with HIV infection in 2011, the most recent year these data are available.

In 2010, white MSM continued to account for the largest number of new HIV infections (11,200), by transmission category, followed closely by black MSM (10,600).

The estimated number of new HIV infections was greatest among MSM in the youngest age group. In 2010, the greatest number of new HIV infections (4,800) among MSM occurred in young
black/African American MSM aged 13–24. Young black MSM accounted for 45% of new HIV infections among black MSM and 55% of new HIV infections among young MSM overall.
Since the epidemic began, an estimated 311,087 MSM with an AIDS diagnosis have died, including an estimated 5,380 in 2012.

Heterosexuals and injection drug users also continue to be affected by HIV.

Since the epidemic began, almost 92,613 persons with AIDS that were infected through heterosexual sex, have died, including an estimated 4,550 in 2012.
New HIV infections among women are primarily attributed to heterosexual contact (84% in 2010) or injection drug use (16% in 2010). Women accounted for 20% of estimated new HIV infections in
2010 and 23% of those living with HIV infection in 2011. The 9,500 new infections among women in 2010 reflect a significant 21% decrease from the 12,000 new infections that occurred among
this group in 2008.

Injection drug users represented 8% of new HIV infections in 2010 and 15% of those living with HIV in 2011.

Since the epidemic began, nearly 186,728 people with (AIDS) who inject drugs have died, including an estimated 3,514 in 2012.

By Race/Ethnicity
Blacks/African Americans continue to experience the most severe burden of HIV, compared with other races and ethnicities.

Blacks represent approximately 12% of the U.S. population, but accounted for an estimated 44% of new HIV infections in 2010. They also accounted for 41% of people living with HIV infection in
2011.

Since the epidemic began, an estimated 270,726 blacks with AIDS have died, including an estimated 6,540 in 2012.

Hispanics/Latinos are also disproportionately affected by HIV.

Hispanics/Latinos represented 16% of the population but accounted for 21% of new HIV infections in 2010. Hispanics/Latinos accounted for 20% of people living with HIV infection in 2011.
Disparities persist in the estimated rate of new HIV infections in Hispanics/Latinos. In 2010, the rate of new HIV infections for Latino males was 2.9 times that for white males, and the rate of new
infections for Latinas was 4.2 times that for white females.
Since the epidemic began, more than 100,888 Hispanics/Latinos with an AIDS diagnosis have died, including 2,155 in 2012.

PEOPLE AT HIGHEST RISK OF AIDS AND HIV INFECTIONS ARE:

● People who share needles
● Men who have sex with other men
● Babies born to mothers who have HIV infections
● People who receive blood transfusions or blood products before 1985
● Anyone who has sex with anyone who has or is at risk for AIDS or HIV infection

HOW IS HIV SPREAD?

HIV is spread through body fluids like blood, pus, semen, menstrual blood, vaginal secretions and breast milk. If your blood comes into contact with any body fluids of an infected person, you may
become infected with HIV. You may expose yourself to HIV if you do any of the following with a person who has HIV.

● Have unprotected sex (sex without a condom)
● You can get HIV from oral, anal, or vaginal sex, or from sharing sex toys with a person who is infected.
● Share a needle or a syringe with someone who is infected.
● This could be sharing a needle to inject drugs, to make tattoos, or to pierce your ear.
● Get infected blood into an open cut or mucous membrane.
● This is rare and usually occurs with healthcare workers when it does happen.
● From a mother to a baby.
This can occur before, during birth or by breast-feeding.

SYMPTOMS
Certain symptoms and conditions may be associated with HIV/AIDS These symptoms and conditions may include: fever, weight loss, swollen lymph glands in the neck, under arms or groin, white
patches in the mouth (thrush), certain cancers (Kaposi's sarcoma, certain lymphomas, certain invasive cervical cancers), and, infections (Pneumocystis pneumonia, certain types of meningitis,
toxoplasmosis, certain blood infections, TB, etc...)

TESTING
A blood test may tell if you have HIV infection or AIDS.
You can get a HIV blood test at your doctor's office or at Counseling and Testing Sites throughout Florida.
Getting tested is easier than ever and can be done confidentially or anonymously which means no one else will ever know you’re at ChoicePoint. They may take a blood sample OR they may
simply take a sample of your spit with a swab. Test results take about 2 weeks to come back and then you can find out the results. Knowing can give you peace of mind and protect other people
that are important to you.

OK, SO TELL ME ABOUT GETTING TESTED...
You can get a free, anonymous HIV test at a local county health department. (see list at the end of this document)
Remember, anyone can get HIV AIDS. Take care of yourself. Protect yourself.

WHAT DOES THIS TEST MEAN?
This test detects antibodies to HIV, not the virus itself. Antibodies are the body's reaction to the virus.
A POSITIVE test means that a person is infected with HIV and can pass it to others. By itself, a positive test does not mean that a person has AIDS, which is the most advanced stage of HIV
infection.

A NEGATIVE test means that antibodies to HIV were not detected. This usually means that the person is not infected with HIV. In some cases, however, the infection may have happened too
recently for the test to turn positive. The Blood test usually turns positive within 1month after infection and in almost all cases within 3 months. Therefore, if you were infected very recently, a
negative test result could be wrong.

FALSE RESULTS (a negative test in someone who is infected, or a positive test in someone who is not infected) are rare. Indeterminate results (when it is unclear whether the test is positive or
negative) also are rare. When a test result does not seem to make sense, a repeat test or special confirmatory tests may help to determine whether a person is or is not infected.

BENEFITS OF BEING TESTED - There are substantial benefits to being tested. Most infected persons may benefit from medications that delay or prevent AIDS and other serious infections. Test
results also can help people make choices about contraception or pregnancy. Therefore, all infected persons should have a complete medical checkup, including tests of the immune system; to
help their health care providers recommend the best health care. There are other reasons to be tested. Even though everyone should follow safer sex guidelines whether or not they are infected
with HIV, many persons find that knowing their test results helps them to protect their partners and themselves. Some persons want to know their test results before beginning a new sexual
relationship or becoming pregnant. Others will be reassured by learning that they are not infected.

RISKS AND DISADVANTAGES of BEING TESTED- Many persons with positive or indeterminate test results will experience stress, anxiety, or depression. Some persons with negative tests may
continue or increase unsafe behaviors, which would increase the risk of HIV infection. Some persons are afraid that their test results will get into the wrong hands, and that discrimination might
result. For these reasons, you should consider your social support (such as family and friends) and your insurance needs before you are tested.

HOW DO I PROTECT MYSELF?

The best way to protect your self is to abstain from sex and to not shoot up drugs.

Here are some ways of limiting your risk of becoming infected with HIV:
● Practice safer sex - (Remember THERE IS NO RISK FREE SEX!)

Have sex with one uninfected partner who only has sex with you. oALWAYS uses a barrier for protection.

● A condom is the most protective prevention strategy. A condom will NOT GUARANTEE that you will not be exposed to HIV but aside from not having sex at all, a condom is your best
defense. Be sure to use a condom for oral sex too!

o Use a water-based lubricant such as KY Jelly, Astroglide, or Wet. Don't use an oil-based lubricant (Vaseline, Crisco, chocolate syrup, etc.). Oil-based lubricants will cause the condom to
break down making holes in the condom that HIV can get through.

o Use latex gloves for hand sex and never use these more than once. When you are done with them, throw them in the trash.
● Don't share needles, razors, or tooth brushes. Something to think about: When you have sex with someone, you could be exposing yourself to everyone that person has had sex with for at
least the past 10 years and everyone those people have had sex with as well.

Don't use drugs (especially drugs you have to inject)
● Using drugs weakens your immune system and makes your body less able to protect itself from becoming infected with HIV.
● Using drugs can affect your ability to make good decisions and you might be more likely to get yourself involved in behavior that will put you at risk.
● If you decide to still use despite these dangers, do not share needles. If you aren't sure if the needles you are using are safe and you decide to use anyway, washing your paraphernalia
(works) in a solution of bleach and then rinsing it with water very well up to 3 times; it may help reduce your chances of contracting HIV. You may want to consider getting treatment for your drug
use.

When cleaning up blood or other bodily fluids:
● Practices called Universal Precaution and Standard Precautions, such as the use of
o Wear gowns, gloves and goggles and always wash your hands thoroughly after contact.
o Always disinfect any areas that may have had blood or other bodily fluids on them thoroughly.

WHAT IF I'M PREGNANT? If you are pregnant, see a doctor. If you have HIV, you can pass it on to your baby before birth, during birth, or through breastfeeding. But there are medications that can make the chances you infect your baby much smaller. Talk to a doctor and get tested for HIV as soon as possible if you think you are pregnant or if you want to get pregnant.

WAYS I WONT GET HIV -

• Shaking hands.
• Eating in a restaurant.
• Using restrooms.
• Donating blood.
• Being bitten by a mosquito or other bug.
• Dry kissing.
• Casual contact like living in the same household, or working with a person who carries HIV. Unless you are exposed to body fluids, you are not at risk for HIV infection.

Tuberculosis (TB)

Tuberculosis (TB) is a disease caused by a bacterium called Mycobacterium Tuberculosis-Tuberculosis (TB) is a disease that is spread from person to person through the air. TB usually affects the lungs. The bacteria are put into the air when a person with TB of the lung coughs, sneezes, laughs, or sings. TB can also affect other parts of the body, such as the brain, the kidney, or the spine. Tuberculosis is a disease that can be cured if treated properly.

TB can affect anyone of any Age-Anyone can get TB, but some people are at higher risk. Those at higher risk include:

● Infants and small children
● People who share the same breathing space (such as family members, friends, coworkers) with someone who has TB disease
● People with low income who live in crowded conditions, have poor nutrition, and have poor health care
● Homeless people
● People born in countries where a lot of people have TB
● Nursing home residents
● Prisoners
● Alcoholics and injection drug users
● People with medical conditions such as diabetes, kidney failure, and those with weakened immune systems (such as HIV or AIDS)

The symptoms of TB disease may include:

Feeling weak or sick, rapid weight loss (over a few weeks or months), fever, or night sweats. Symptoms of TB of the lungs may include: cough, chest pain, or coughing up blood. Other symptoms
depend on the particular part of the body that is affected.

TB infection is different than TB disease:
People with TB disease are sick from bacteria that are active in their body. They usually have one or more of the symptoms of TB. These people are often capable of giving the infection to others.
Medications can cure TB disease; usually three or more medications are given to treat TB disease. People with TB infection (without disease) have the bacteria that cause TB in their body. They
are not sick because the germ lies inactive in the body. They cannot spread the germ to others. Medications are often prescribed for these people to prevent them from developing TB disease in
the future.

A skin test can tell if you have TB infection:

You can get a TB skin test from a doctor or local health department. A negative test usually means the person is not infected. However, the test may be falsely negative in a person who has been
recently infected (it usually takes 2 to 10 weeks after exposure to a person with TB disease for the skin test to be positive). The test may also be falsely negative if the person’s immune system is
not working properly.

A positive skin test reaction usually means that the person has been infected with TB. It does not necessarily mean that the person has TB disease. Other tests, such as an x-ray or sputum
sample, are needed to see if the person has TB disease.

If you have TB infection or disease:

● Do all the required tests that your doctor orders.
● Stay at home until your doctor tells you it is okay to return to work or school. Do not have visitors (especially children) until your doctor says it is okay.
● Keep all your medical appointments.
● Take all your TB medications as prescribed. In Maryland, the local health department works with doctors to treat almost all people with TB disease. The local health department will provide
the correct antibiotics and make sure they are taken correctly. Medications must be taken for long periods of time (6 months or more).

Adapted from Centers for Disease Control “Tuberculosis-Get the Facts!"

STD Frequently Asked Questions

All of these diseases are passed on by having unprotected sex (any kind of sex) with someone who is infected. You cannot tell someone is infected by his or her looks!! Remember, STDs including HIV (the virus which causes AIDS) is passed by having unprotected sex.

Primary Syphilis

● Infectious agent is the spirochete Treponema pallidum.

● Symptoms -non-painful sore on genital area (outside or inside) or on lip or inside mouth, caused by sexual contact with someone who has a primary syphilis sore.

● Frequently asked questions -
o Do I always know I have it? No, the sore may be where you can't see it (inside vagina, for example).
o Does the sore last a long time? No, the sore is only present for one or two weeks, then no symptoms until the next stage, secondary syphilis.
o Can a pregnant woman pass syphilis on to her unborn baby? Yes, a pregnant woman with syphilis who is not treated early enough can pass syphilis on to her baby, who can be born
critically ill.

Secondary Syphilis

● Infectious agent is the same as primary syphilis above.

● Symptoms -non-painful, non-itchy rash typically on palms of hands, soles of feet, may be anywhere on the body. Rash is often spots which are darker than the normal skin color.
● Frequently asked questions -

o Is the rash contagious? Yes, the rash is very contagious.
o Is syphilis curable? Yes, it is easily curable with the right type and amount of penicillin.
o What if l am allergic to penicillin? Another type of antibiotic may be used.

Herpes

● Infectious agent is the herpes simplex virus.
● Symptoms -painful blisters on genital area can come and go. Some people have sores that are so mildly painful that they do not know they have them. Others also can have sores in areas
that are not seen, again like in the vagina, or mouth.

● Frequently asked questions

o Can I get herpes or pass it on even if there are no sores present? Yes, it may be possible to get it or pass it on even if no sores are present.
o How long does the infection last? It will remain in your body for the remainder of your life. You can be infectious to others at periodic times for many years.

Chlamydia

• Infectious agent is Chlamydia trachomatis, a bacteria.
• Symptoms -yellow or mucous-like discharge from the vagina or penis. Usually the discharge is of a small amount. Most people do not have any symptoms.
• Frequently asked questions -
o Can Chlamydia cause me to become sterile? Yes, untreated Chlamydia can cause infertility or long-term pelvic pain.
o Can I have it and not know I have it? Yes, you may not have any symptoms but be infected for several years.

Gonorrhea
• Infectious agent is Neisseria gonorrhoeae, a bacteria.
• Symptoms -yellow or greenish or mucous-like discharge. A female may have burning urination or pelvic pain. A male often may have burning urination, and may notice a stain in his
underwear.

• Frequently asked questions -
o Can a male have gonorrhea and not know they have it? Yes, it is possible to not have any symptoms. It is more likely that a female would have milder symptoms, or not have any
symptoms that for a male.

Genital warts
• Infectious agent is the human papillomavirus (HPV).
• Symptoms - cauliflower-like warty growths that may be on the genital area, outside or inside.
• Frequently asked questions -
o Why do I have these warts and my partner doesn't? It is possible for one person to have genital warts and their partner to be free of warts.
o I was told that I have an abnormal Pap smear caused by this virus, why didn't I have warts? There are several types of HPV, some of which cause genital warts and some cause abnormal
Pap smears. I have heard warts cause cancer, is this true? Yes, some types of HPV do cause cervical cancers in women and penile cancer in men.
Remember: If you know you have an STD like Herpes or HPV (genital warts) or HIV, you must protect your future partners from infection. You must tell them before having sex and use condoms if
you do have sex.

NOTE: ZIKA and EBOLA are also reportable diseases.

We will be glad to assist you in accessing medical health services if that is needed. If there is an accident, injury or event that occurs while you are on the premises that present a potential risk, we
will take the appropriate action to facilitate medical intervention and take all necessary precautions to protect other clients and staff from possible exposure to communicable diseases. Staff will
provide you with written information on specific infection control procedures and Universal Precautions procedures to help protect yourself and avoid risky behaviors. (See handouts from Staff)

USE PROPER HANDWASHING TECHNIQUES --- PROTECT YOUR HEALTH

Handwashing is the single most important procedure for preventing the spread of biological contamination. Despite this fact many laboratory personnel don't wash their hands properly. Here are
some hand washing tips and procedures for your use.
1. Consider the sink, including the faucet controls, contaminated.
2. Avoid touching the sink.
3. Turn water on using a paper towel and then wet your hands and wrists.
4. Work soap into a lather.
5. Vigorously rub together all surfaces of the lathered hands for 20-60 seconds. Friction helps remove dirt and microorganisms. Wash around and under rings, around cuticles, and under
fingernails
6. Rinse hands thoroughly under a stream of water. Running water carries away dirt and debris. Point fingers down so water and contamination won't drip toward elbows.
7. Dry hands completely with a clean dry paper towel.
8. Use a dry paper towel to turn the faucet off.
9. To keep soap from becoming a breeding place for microorganisms, thoroughly clean soap dispensers before refilling with fresh soap.
10. When handwashing facilities are not available at a remote work site, use an appropriate antiseptic hand cleaner or antiseptic towelettes. As soon as possible, rewash hands with soap and running water.

Cough Etiquette

Cover Your Couch: Stop the spread of germs that can make you and others sick!

Influenza (flu) and other serious respiratory illnesses, like respiratory syncytial virus (RSV), whooping cough, and severe acute respiratory syndrome (SARS), are spread by cough, sneezing, or unclean hands.

To help stop the spread of germs:
● Avoid close contact with people who are sick.
● Stay home when you are sick.
● Cover your mouth and nose with a tissue when you cough or sneeze.
● Wash your hands often with soap and warm water for 20 seconds. If soap and water are not available, use an alcohol-based hand rub.
● Avoid touching your eyes, nose or mouth.
● Practice other good health habits. Clean and disinfect frequently touched surfaces at home, work or school, especially when someone is ill. Get plenty of sleep, be physically active, manage
your stress, drink plenty of fluids, and eat nutritious food.

At ChoicePoint, client’s mental and physical health are important to us. We believe in evidence-based treatment and harm reduction. A primary component of these treatments involves Medication
Assisted Treatment, also known as MAT. ChoicePoint utilizes suboxone and vivitrol as forms of MAT. Medication is only part of MAT treatment, with the clinical component being equally as crucial.
Therefore, at ChoicePoint a client must participate in both the clinical and medication components of MAT treatment. These are not only ChoicePoint’s guidelines, we are also bound by the NJ
Department of Health and Drug Enforcement Agency to ensure that all of our MAT patients are receiving clinical treatment along with medication.
Clients who come to ChoicePoint and require MAT, Medication assisted treatment, have special protocol for acceptance.

Procedure:

1. Upon admissions clients will be assessed on whether they may be appropriate for MAT treatment.
2. If appropriate for MAT treatment, a client wishes to engage in MAT treatment will be assessed with a registered nurse.
3. Drug testing must be conducted prior to the prescribing of MAT medication. New Jersey DHMAS also requires lab testing that may be done at our Fair Lawn location, or a referral to a local
Labcorp, Quest, or other blood lab may be provided.
4. MAT levels are verified frequently through drug testing randomly, weekly or as needed. Failure to submit a drug test will result in no prescription or refill being ordered until completed and
results are assessed. We offer remote drug testing, but if compliance can be maintained, you may be asked to drive to ChoicePoint for an in-person drug testing, or another drug testing laboratory.
5. Physician will conduct a History and Physical exam with you and if appropriate, begin your MAT protocol.  Wave!

Rules and Expectations
6. All medications must be taken as prescribed.
7. You may be given a 1-3 day initial prescription to assess how you react with the medication, and any adjustments needed will be made.
8. You are required to see the doctor weekly for the beginning phase of the program, and will not have longer than 7 days of medication prescribed.
9. Individuals placed in the Intensive Outpatient Program (IOP) must attend 3x group sessions per week, along with 1x individual counseling sessions.
10. Individuals placed in the Outpatient Program(OP) must attend the recommended groups and individual sessions outlined by your clinician.
11. Failure to attend the required drug testing, clinical, or medical appointments may result in the delay or denial of your medication refill. It is imperative that any attendance issues are brought
forth to your counselor with proper notice. Suboxone is a controlled substance, and we at ChoicePoint take the prescribing of it very seriously. If you fail to meet the required attendance you may
be put on a Behavioral Contract. If the Behavioral Contract is violated you may be discharged from the program for non-compliance.

BUILDING AND PROGRAM RULES

BUILDING RULES: No smoking or vaping electronic cigarettes inside of the building

ATTENDANCE AT SCHEDULED TREATMENT SESSIONS IS REQUIRED ABSENCES MUST BE APPROVED BY STAFF OR MAY RESULT IN CONSEQUENCES OR UNSUCCESSFUL
COMPLETION OF THE PROGRAM

PAYMENT OF GROUP FEES :

* Fees are due and payable when services are rendered.
* Methods of payment include: Cash, Check, Money Order, Credit/Debit Card
* If you give CHOICEPOINT a check that is returned for any reason, you will be charged a $25.00 service charge and we will no longer accept checks from you.
* You must be paid in full (including clearance of all checks) prior to receiving a Certificate of Completion.

GROUP RULES:

* No Couples in groups together.
* No vaping in groups allowed.
* No phones allowed in groups or on the facility. Failure to abide by this rule may result in your being asked to leave the group without receiving credit for the session.
* Participants must keep the CHOICEPOINTs of all participants confidential.
* Participants must refrain from using sexist or racist language.

INDIVIDUAL RULES:

* Participants must be on time for the individual appointment.
* No phones are allowed in session.
* Any change in level of care is decided clinically by the primary clinician and clinical director.

PROGRAM RULES:

* All program participants (group and individual) must do all assignments to receive credit for each session.
* More than 3 unexcused absences may result in administrative termination/discharge.
* A leave of Absence must be approved by the clinician and clinical director. Approvals are on an individual bases and for extenuating circumstances.
* Any leave of absence lasting more than 3 days will require a discharge from the program.
* Any participant who is negatively terminated for noncompliance with program rules (including excessive absences) will be required to start the program over from session #1 without credit for
sessions previously attended.

DRUG / ALCOHOL POLICY: It is the policy of CHOICEPOINT Center to advise all clients at the time of intake that it is strictly prohibited for clients to come to any group/individual appointment
under the influence of alcohol and/or drugs.
1. Any client who appears to be under the influence of alcohol and/or drugs is subject to be tested by CHOICEPOINT staff at his/her own expense.
2. A client under suspicion will be addressed directly by CHOICEPOINT staff.
3. If a client denies that he/she is under the influence of alcohol and/or drugs, he/she may be subject to drug testing at his/her own expense.
4. If the client tests positive then one of two things will take place.
a. If the client is not under probation or court order to abstain from alcohol/drugs the counselor will evaluate the client and assign them to additional services within our agency as assessed to
be clinically appropriate; or
b. If the client is under probation or court order to abstain from alcohol/drugs the client may be administratively discharged, and the proper authorities contacted.
5. If the client is required to be tested by staff and refuses, it will be considered a positive test and the client may be administratively discharged from the program. Above conditions will not
apply due to unaccountability of client behavior.
6. If the client is tested due to suspicion and tests negative, the client shall continue his/her program without any additional services. However, the client will be monitored for the duration of
their program.

Cardinal Rules: The following rules address issues that have the potential for significant consequences. Because of that potential risk, any deviation from either the letter or the spirit of the
following rules necessitates both: 1) an immediate and definitive response aimed at addressing or preventing any immediate negative consequences; 2) a follow-up staffing to be conducted as
soon as realistically possible in order to determine an individualized response consistent with the purposes and values of ChoicePoint Center program. If the staffing does not prove to resolve the
issue and honor the core values of the program, consequences up to and including discharge can be the result.

Violence or Threat of Violence: The safety of all is of paramount importance. Should any violence occur, authorities will be immediately summoned to take appropriate legal action and to assist
in restoring a safe environment. Likewise, anyone who reasonably believes that they are being threatened by any form of physical violence must report this threat to staff. All clients must
cooperate with staff as they take appropriate action to de-escalate situations and to restore order and safety. Failing that, authorities will be summoned whenever necessary to ensure the
protection and safety of all clients and staff. In addition, behaviors such as profanity, yelling, and aggressive confrontation will not be permitted.

Weapons: Again, for the safety and security of all concerned, no firearms or other obvious weapons or other items deemed hazardous by staff will be allowed anywhere on the premises. If any
firearm or other obvious weapon is discovered, authorities will be summoned to take possession and remove the item from the premises. Any item, which in the opinion of a staff member, is
considered to present a current or potential threat must also be immediately surrendered when requested by staff for appropriate disposition. Refusal to do so is to be considered as a threat of
violence and will be handled as such. We have a duty to report to authorities anyone who we suspect of potential violence and who has access to a gun or other weapons.

Illicit Drugs and Alcoholic Beverages: The presence of illicit drugs or alcoholic beverages are prohibited on the premises or on the property at any time. Should any illicit substance be
discovered, staff will be notified to take possession of the substance. Should any alcoholic beverage be discovered, staff will immediately take possession and dispose of the beverage. Clients
who introduce Alcohol/Drug contraband, and/or paraphernalia into the facility will be immediately discharged.

Sexual Intimacy: Because of disruption that sexual and/or personal relationships between clients can have on one’s progress within a treatment environment, it will be necessary not to permit any
such behavior anywhere on the premises while you are a client. This includes male to male, male to female, female to female sexual behavior. Should any behavior be discovered that is deemed
by a staff member to be sexual in nature, that staff member will direct the clients involved to immediately cease the behavior. A staffing will be conducted to arrive at an appropriate disposition
which can result in discharge from the agency. This policy includes sexually suggestive conversations, hand-written notes, sex-texting, or wearing attire that is inappropriate such as tank tops,
short shorts, etc. Clients are encouraged to report instances of observed sexual behaviors to staff if staff are not present.

Pregnancy: The following procedure will take place in the event that a client becomes pregnant while in our care; Client will receive the appropriate referrals and will be connected to community
providers to assist with obtaining any eligible benefits if needed such as Medicaid, WIC, Food stamps etc. Clients will also be offered at least (3) community providers as referrals which can offer
the appropriate care for pregnancy. Client will be given an adequate amount of time to develop a safe and appropriate discharge plan with assistance from clinical director, clinician and case
manager if needed. Client will smoothly transition out of our care and housing into an alternative facility/program for ongoing care if needed. Should a client refuse to accept clinical
recommendations for ongoing care, the client will then have two weeks to develop their own discharge plan.

Expectations: The following expectations are important guidelines also meant to further ensure an environment that is healthy, secure and conducive to every client successfully accomplishing
the goals and objectives of their stay at CHOICEPOINT. We do require that these expectations be followed and any deviation from the spirit of these expectations will necessitate a follow-up
staffing be conducted as soon as realistically possible in order to determine an individualized response consistent with the purpose and values of the CHOICEPOINT Program.

Staff Direction: All staff are obligated to ensure the safe, secure and smooth operation of our residence. In order to facilitate accomplishing that task, and within a climate of partnership and
mutual respect, it is necessary to expect that all clients will comply with directions given by staff in a timely and respectful manner. Should there be any disagreement with any directions given by a
staff member, for the purpose of expediency, we expect clients to comply with that direction but also to follow the appropriate grievance procedure so that their perspective can be heard and
addressed.

Being Under the Influence: Because this program is not able to guarantee the medical and personal safety of anyone who is under the influence of drugs or alcohol, if you, a visitor or guest
arrive at the facility under the influence of alcohol or drugs, you will not be permitted to remain in the facility. If you are found to be under the influence of alcohol or drugs while at the facility, you
will be offered the option of transport to a detox unit.

Drug/Alcohol Screen/Breathalyzer: UA’s/breathalyzers are performed prior to admission, at random and based on observable behavior. A refusal is considered a positive screen. Tampering with
the urine sample is considered a positive screen. If a positive screen/breathalyzer is obtained, the client will discuss with the counselor and make the appropriate clinical and medical determination
to move forward.

Smoking: In accordance with state rules and regulations, smoking/vaping cannot be permitted anywhere within the facility at any time and will be allowed only in designated areas outside.

Building Security: We respect the tenets of the building and environment in which our offices reside and we ask that you remain aware that we share the space with other businesses and the
public. Please be considerate of the overall building hours and rules.

Client Whereabouts: If you are here for day or evening Intensive Outpatient, Day or Night treatment programs or for any appointment please do not leave the area without notifying the front desk
of your whereabouts and how we can contact you if need be.

Confidentiality: Every resident has the right to confidentiality and every effort will be made to protect that confidentiality. Without written approval from the resident, it is inappropriate for any
information concerning any resident to be revealed to any person or organization outside of this facility. Likewise, it is inappropriate to acknowledge if someone is, or has been, a client of this
program. NO CAMERAS MAY BE USED ON OUR PREMISES FOR ANY REASON!

Visitors: Visitors must be pre-approved by your therapist. Consistent with the above confidentiality issues, clients must provide a written release of information and written consent before visitors
can be allowed access to other clients or our facility. All visitors must be sober, and follow the rules of conduct outlined in the handbook. If not, they will be required to leave the premises
immediately.

Cell Phones: Phones are not permitted during clinical hours. If any client is found in possession of a cell phone, they will be asked to turn it off or hand it in to staff and it will be locked up until the
end of the clinical day.

AMA POLICY: Any client who decided to leave treatment prematurely, against medical advice/against clinical advice will not receive their personal property. ChoicePoint has the right to hold the
client's property for up to 24 hours after point of discharge.

Client Medications Upon Discharge: It is the policy of the agency that clients will not take possession of their medications upon leaving the program unless it is an approved discharge and
taking possession of the medications is specifically authorized by the Medical Director. If you are transferring to another treatment agency/provider, then we will be glad to arrange for transfer of
the medications directly to the new provider. If you leave against advice or you are administratively discharged, then your meds will remain here and will be disposed of within 30 days unless you
transfer to another provider.

No loaning or borrowing from fellow clients: Loaning or borrowing money or property from fellow clients is prohibited. It interferes with treatment relationships within the community. Let staff
know what your needs may be.

PLEASE ACKNOWLEDGE BELOW WITH INITIALS

Consent to Obtain & Release Information

The information to be disclosed/obtained is (please check items to be disclosed/obtained):

I understand that by law, I need not consent to the release of this information. However, I choose to do so willingly and voluntarily for the purpose specified above.

I understand that my drug and alcohol treatment records are protected under the Federal regulations governing confidentiality and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health
Insurance Portability and Accountability Act (HIPAA) of 1996, 45 C.F.R. Parts 160 & 164, Subparts A and E, and cannot be disclosed without my written consent unless otherwise provided for by
the regulations. “A General authorization for release of medical or other information is NOT sufficient for this purpose." The Federal rules restrict any use of the information to criminally investigate
or prosecute any alcohol or drug abuse patient. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event
this consent expires one year after the signed date.

I understand I am entitled to a copy of this document in its complete form:
My signature verifies that I have received a copy of this release.

Consent to Obtain and Release Confidential Information