Welcome

Client Information

Basic information about the person being admitted to the program.

Outpatient Service Agreement

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

1. Initials *

   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. Initials *

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

3. Initials *

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

4. Initials *

   I fully understand the Fee Schedule is as follows:

   • Initial Evaluation (2 sessions: 90 min & 60 min) — $265.00
   • Group Sessions (in-person/virtual, up to 90 min) — $40 each
   • Individual Sessions (in-person/virtual, 45–60 min) — $90 each
   • Discharge Session (45–60 min) — $90.00
   • Alcohol/drug screening (random) — $35.00 each

   Onsite drug/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. The patient authorizes release of insurance information to the laboratory for billing purposes and agrees to be fully responsible for any costs not covered by insurance. Fee schedule may be subject to change; 15-day notice will be provided.

5. Initials *

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

6. Initials *

   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.

7. Initials *

   To remain active, I must participate in at least 4 sessions within every 30-day period. Not doing so will result in a $50 fee to avoid inactive status. The only exceptions require a medical excuse.

8. Initials *

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

9. Initials *

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

10. Initials *

    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.

Financial Agreement

Electronic Information Agreement

I authorize House of Freedom personnel to contact me through the following unsecured email address(es). This information may contain personal information such as appointment schedules, progress reports, medical information, account information, and complaint reports. By signing, I release House of Freedom of any responsibility for lost or misused information sent via email.

General Rules & Information

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 to avoid a zero for that session. Sessions that receive a zero cannot be made up.
2. All information shared during group and individual sessions should be treated as CONFIDENTIAL.
3. Clients are expected to treat staff and each other with respect. Verbal abuse is prohibited.
4. Any behavior that disrupts meetings and activities is UNACCEPTABLE (side conversations, interrupting, etc.).
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 property. All clients and staff are responsible for reporting any damage.
7. Clients must ARRIVE ON TIME and complete ALL reading and writing assignments to be given full credit for a session.
8. Dress code. 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 is not permitted. Revealing or distracting attire — including midriff or crop tops, bralettes, sports bras, leggings worn as pants, workout attire, cut-off shirts, short shorts, or skirts/dresses above mid-thigh — is not allowed. Clients arriving dressed inappropriately will be asked to leave, will not receive credit, and fees will not be refunded.
9. Clients must provide random urine samples for drug screening when requested. Refusal is recorded as an administrative positive test. Random tests are generally conducted outside of scheduled appointments; clients must report on-site for testing within six (6) hours of receiving a request from HOF staff.
10. No more than three warnings are allowed. More than three warnings could result in dismissal from the program (unsuccessful discharge).
11. No drugs, alcohol, or nicotine products are allowed on the premises of House of Freedom.
12. Clients are not allowed to use drugs, alcohol, or nicotine products on the premises, including parking lots. Smoking/vaping must be done before/after arriving or across the street.
13. Clients must disclose any prescription or over-the-counter medications to HOF staff and provide written verification from a licensed medical professional confirming medical necessity. Failure to disclose or provide documentation may result in program consequences, including being considered noncompliant.
14. Clients of the outpatient program are to have NO CONTACT with clients from the residential program. Any contact deemed unhealthy can be grounds for dismissal.
15. Records requests MUST be done in writing through the patient portal. All requests are processed within 10 business days.
16. Patient progress upgrades for probation officers MUST be requested in writing by the patient or the probation officer.

Authorization for Use or Disclosure of Information

I authorize House of Freedom (HOF) to use and/or disclose the following protected health information as indicated below.

Medical History Screening

Medical History — History Of

9. Please answer each item. If you answer Yes to any, add a comment in the box below it.

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.