Outpatient Program · Safety Council Referral
2311 N. Orange Blossom Trail, Kissimmee, FL 34744 · 407-957-9077

Welcome

Thank you for choosing House of Freedom (HOF) as your behavioral health provider. We are committed to your treatment and expect that you will be equally committed. Please read all of the following information carefully, including this introduction.

  • HOF is a non-profit, faith-based substance abuse treatment center licensed by the Department of Children and Families. We offer a wide array of services to meet your individual needs, including outpatient services, residential treatment, psychiatric care, brain SPECT imaging, neurotransmitter analysis, genetic testing, and more.
  • During your treatment experience, and based on your individual needs, your treatment plan may include a variety of services such as drug and alcohol evaluations (based on the Addiction Severity Index), random drug testing, group, individual, and family counseling, life skills training, relaxation exercises, participation in religious services and/or self-help groups, and relapse prevention planning to help you prepare for a drug-free life.
  • Our mission is to provide comprehensive, individualized care in a safe and compassionate environment, allowing each person served the opportunity to attain and maintain their highest possible physical, psychological, and spiritual well-being. This is accomplished through our core principles of Caring, Compassion, and Commitment, while incorporating each client’s strengths, input, abilities, preferences, unique circumstances, and available resources throughout the treatment experience.
  • We will not share any confidential information with any person or organization without your written consent, except as permitted or required by law.
  • Your participation in services at HOF is voluntary, and you may withdraw at any time. When clinically appropriate, your case may be staffed with other HOF therapists if you or your therapist believe it would be beneficial to your treatment.

This online packet replaces the paper intake forms. It takes most people about 15–20 minutes, and you’ll sign several sections by drawing with your finger or mouse.

Client Information

Basic information about the person being admitted to the program.

Financial responsibility

I certify that my name is and I will be responsible for all/any payments rendered to House of Freedom for the services that will be provided to my .

Outpatient Service Agreement

Please read each statement and initial each one to acknowledge your understanding. All ten initials are required before you can continue.

Financial Responsibilities

  1. I have been explained and fully understand the financial responsibility that I have, in order to be provided the services stipulated in my treatment plan.

  2. At the time of admission, I am depositing $ which covers one screening/assessment session, one treatment planning session, and one drug screening.

  3. I understand that I am responsible to bring the payment in full for each session before I can be provided the service.

  4. Fee Schedule

    I fully understand the Fee Schedule is as follows:

    • Initial Evaluation (2 sessions: 90 minutes & 60 minutes) — $265.00
    • Group Sessions (In-person / Virtual) (up to 90 minutes) — $40 each
    • Individual Sessions (In-person / Virtual) (45-60 minutes) — $90 each
    • Discharge Session (45-60 minutes) — $90.00
    • Alcohol/drug screening (Random) — $35.00 each
      • Onsite drug and/or alcohol screenings are $35.00 per test
      • The provider reserves the right to send any specimen to an external laboratory for additional or confirmatory testing at its discretion
      • The client authorizes the release of their insurance information to the laboratory for billing purposes
      • The client agrees to be fully responsible for any and all costs associated with laboratory testing not covered by insurance for any reason, including but not limited to deductibles, co-pays, co-insurance, denied claims, or any additional charges billed by the laboratory

    *Fee schedule may be subject to change; in which case a 15-day notice will be provided.

  5. Non-refundable Policy

    I understand that House of Freedom is not responsible or does not guarantee any outcome, for this reason, if I am ever unsatisfied or wish to discontinue my treatment or in fact never begin my treatment, any and all of the money that is deposited is nonrefundable.

  6. Program Start Requirements

    I understand that I have up to 15 days to begin an active role in treatment, if I have been inactive for 15 days a letter will be sent to my referral agency and the process of admission and payments must be rendered again.

Attendance & Participation

  1. Session Requirements

    In order to remain active, I understand that I must participate in at least 4 sessions within every 30-day period, not doing so will result in a $50 fee in order to avoid an inactive status.

    • The only exceptions made will require a medical excuse.

  2. No-show Policy

    I understand that if I register for a session and fail to attend, I will not receive credit for the session, and the fee paid for that session will not be refunded.

  3. Late Policy

    I understand that if I arrive more than five (5) minutes late to a session, I will not be permitted to enter, will not receive credit for the session, and the fee paid for that session will not be refunded.

Program Limitations

  1. No Medical Services Included

    I understand that the services do not include the provision of medical services (e.g., physical exams or prescribing medications). However, clients may use prescribed medications as authorized and verified by a licensed medical provider.

With my signature I declare on this that I have read and fully understand the terms and conditions of this agreement.

Financial Agreement

I, , Relationship to client , am rendering payment in the amount of $ for the services fees agreed upon for client .

Choose any/all of the services that you are requesting *

Check all that apply.

  • Onsite drug and/or alcohol screenings are $35.00 per test
  • The provider reserves the right to send any specimen to an external laboratory for additional or confirmatory testing at its discretion
  • The client authorizes the release of their insurance information to the laboratory for billing purposes
  • The client agrees to be fully responsible for any and all costs associated with laboratory testing not covered by insurance for any reason, including but not limited to deductibles, co-pays, co-insurance, denied claims, or any additional charges billed by the laboratory

*Fee schedule may be subject to change; in which case a 15-day notice will be provided.

Choose one (1) of the following payment methods *
Sensitive information. The form will transmit your card details to House of Freedom.

I, , authorize House of Freedom to charge my credit card the amount of $ . (A transaction fee applies to all credit card transactions)

Credit card information *

Important Note: Please send a copy of driver’s license or photo ID & copy of front & back of credit card.

WE DO NOT ACCEPT PERSONAL CHECKS

Authorized date:

Electronic Information Agreement

I, , authorize House of Freedom personnel to contact me through the following unsecured email(s):

(Client / Parent / Guardian / Financial Custodian printed name)

I understand this information may contain personal information such as, but not limited to: Appointment schedules, Progress Reports, Medical Information, Account Information and Complaint Reports.

By signing, I release House of Freedom of any responsibility. Neither House of Freedom, Inc., nor its subsidiaries or affiliates, will be liable for any lost or misused information, damages resulting from any modification or falsification of an e-mail that is originated by House of Freedom, Inc. Moreover, although precautions have been taken to ensure that the data included herein is free from viruses or other malicious content, House of Freedom, Inc. cannot assure that such is indeed the case and disclaim any responsibility attributable thereto.

Date:

General Rules & Information (OP Program)

Please read each rule carefully. You will acknowledge and sign below.

  1. The client MUST attend all group, individual and family sessions, if requested, and is responsible to be ON TIME. Absences require staff’s permission in order to avoid a zero for that session. Sessions that receive a zero cannot be made up.
  2. All of the information shared during group and individual sessions should be treated as CONFIDENTIAL information.
  3. Clients are expected to treat staff and each other with respect. Clients can expect to be treated with respect by the staff. (Verbal abuse is prohibited)
  4. Any behavior that disrupts meetings and activities is UNACCEPTABLE (ex. Side conversations, interrupting).
  5. There should be no physical contact between clients. Physical assault is grounds for dismissal from the program.
  6. Clients and/or their families will be charged for any physical damage to the property. All clients and staff are responsible for reporting any damage to property.
  7. Clients must ARRIVE ON TIME & complete ALL reading and writing assignments in order to be given full credit for that session.
  8. Dress code:
    1. Clients are expected to dress appropriately at all times. Shoes and socks must be worn. Clothing that displays or promotes drugs, alcohol, violence, profanity, or other offensive or inappropriate content (including certain graphic or band-related imagery) is not permitted. Additionally, revealing or distracting attire is not allowed. This includes, but is not limited to, midriff or crop tops, bralettes, sports bras, leggings worn as pants, workout attire, cut-off shirts, short shorts, or skirts/dresses that fall above mid-thigh.
    2. If a client arrives dressed inappropriately, they will be asked to leave, will not receive credit for that session, and the fee paid for that session will not be refunded. Repeated violations of the dress code will be addressed on an individual basis.
  9. Clients will be required to provide random urine samples for drug screening. Refusal to comply will be recorded as an administrative positive test. Random alcohol and drug tests will generally be conducted outside of scheduled appointments. Clients are required to report on-site for testing within six (6) hours of receiving a request from HOF staff.
  10. There are no more than three warnings allowed. More than three warnings could result in dismissal from the program (unsuccessful discharge).
  11. No drugs, alcohol, or nicotine products are allowed in the premises of House of Freedom.
  12. Clients are not allowed to use drugs, alcohol, and/or nicotine products in the premises of House of Freedom including parking lots. Smoking and/or vaping must be done before or after arriving to the program or across the street from our property.
  13. Clients must disclose any use of prescription or over-the-counter medications to HOF staff. Clients are required to provide written verification from a licensed medical professional confirming that the medication is medically necessary. Failure to disclose medication use or provide required documentation may result in program consequences, including being considered noncompliant.
  14. Clients of the outpatient program are to have NO CONTACT with the clients from the residential program. Any contact that is deemed unhealthy can be grounds for dismissal of the program.
  15. Records requests MUST be done in writing through the client portal. All requests will be processed within 10 business days.
  16. Progress reports for probation officers MUST be requested in writing by the client or the probation officer.

Date:

Authorization for Use or Disclosure of Information for Purposes Requested by House of Freedom, Inc.

I, , hereby authorize House of Freedom, Inc. (HOF) to:

Authorized recipients

The following blanks should contain the names of the people whom the client authorizes to obtain information regarding his/her treatment. Ex. Parents, spouse, children, agency, probation officers, financial custodians, etc.

This protected health information is being used or disclosed for the following purposes: *

This authorization shall be in force and effect until at which time this authorization to use or disclose this protected health information expires. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to House of Freedom, Inc. at PO Box 423202, Kissimmee, Florida, 34742. I understand that a revocation is not effective to the extent that House of Freedom, Inc. has relied on the use or disclosure of the protected health information.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. Refusing to sign this will not condition my treatment, payments, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure. I understand that I have the right to:

  • Inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights).
  • Refuse to sign this authorization.

The use or disclosure requested under this authorization will result in direct or indirect remuneration to House of Freedom, Inc. from a third-party (if applicable).

Date:

Medical History Screening Form – Outpatient

3a. Current medications
Medication Why are you taking this medicine? How is it working for you?
3b. Previous medications
Medication Why were you taking this medicine? How did it work for you?

Medical Screening Form (Continued)

9. Please answer the following: (If you answer yes to any of the below statements, please comment in the box provided or in section 10.)

Review & Submit

Please review the summary below. When you submit, a completed PDF will be emailed to House of Freedom and (optionally) a copy will be sent to you.

✓

Thank you

Your intake packet has been submitted. A copy has been sent to House of Freedom, and someone from the team will be in touch shortly.

If you provided your email, you should receive a confirmation copy within a few minutes. If you don't see it, check your spam folder.