Eternal Warriors Men of Moroni

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Erik Young
6 years ago
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1 Personal information: Eternal Warriors Men of Moroni 877-HERO-877 ( ) Life Changing Services APPLICATION First name: Last Name: Date: / / Street address: City: State: Zip: Home Phone: Business Phone: Cell: Birth date: / / Employer: Spouse Information (If applicable) First Name: Last Name: Street address: City: State: Zip: Home Phone: Cell: Birth date: / / Employer: Permission to contact wife about WORTH (Women of Rebirth Therapeutic Healing) Free: Yes No: Signature: Bishop s name: Ward: Ph# Street Address Permission to contact Bishop: No Yes Signature: Notice: Men of Moroni is an intensive education/training program not a therapeutic program. Men of Moroni Mentors are certified by Life Changing Services and do not have a therapy license.

2 PAYMENT OF SERVICES- CHECK ONE Men of Moroni will be billed as follows: $25 per week to participate in the weekly group meetings, this includes the group, or $15 per week to participate in the group only. Please indicate the charges that apply to you: Men of Moroni Group only ($15/week) Men of Moroni Group Meeting (Also includes access) ($25/week) Option A: Cash or Check Individual Paying Name Phone Option B: Check/Bishop Pay If indicated that a bishop will be paying any portion of your bill, the Authorization for Release of Confidential Information on the previous page will need to be signed so we can contact that bishop and verify the information regarding your billing/payment arrangements. If there is a change in bishops during the course of treatment, and you want the new bishop to continue payment for services, you must notify the new bishop and Karen at 877-HERO-877or The new bishop will need to be added to this Authorization for Release of Confidential Information form. If you will be receiving Bishop s assistance, please complete the following information: Ward: Bishop Phone Number: Bishop Complete Address: Option C: Credit Card If you would like your credit card billed automatically each week: Circle: Visa MasterCard Name as appears on card: # Exp: / Signature: Any payment questions contact Karen at 877-HERO-877or or sofhoutreach@gmail.com

3 DESCRIPTION OF SERVICES- Eternal Warriors - Men of Moroni We welcome you to Life Changing Services, and hope that your visit will be worthwhile. The following information is important for your consideration; your goals are more likely to be met when you understand the nature and limitations of life-coaching. Goals and Outcomes Generally, coaching is most useful in helping individuals help themselves or improve their relationships by changing feelings, thoughts, or behaviors. You determine the nature and amount of change you wish to make. Benefits and Risk Most people experience improvement; of course, there are no guarantees; and there are some risks. For example, this coaching could open up new levels of awareness that may cause discomfort. Length of Class Attendance Length of attendance is determined by the client. Mentors will make suggestions, but the client needs to balance the pain he/she is experiencing with their financial situation. Absence from group On occasion, a situation may arise which prevents you attending class. Please notify your mentor in advance if you will not be attending. You will be personally billed for no shows. We will not bill your bishop. Confidentially We understand the information you share can be very personal and that you may not want us to disclose this information to the others without your authorization. The Life Changing Services Notice of Privacy Practices informs you of your rights and obligations regarding the use and disclosure of health information. All clients will be asked to sign a Services General Authorization. Agency personnel will not release confidential information without this written authorization, unless such a release is otherwise authorized or required by the law. Grievance You have every right to be treated with respect and dignity in a safe environment. Discrimination by our staff is not tolerated, if you have concerns about the services you receive, talk to your mentor or make an appointment with the agency director who will assist you. Money To participate in Eternal Warriors Men of Moroni, there is an initial registration and materials fee of $50 plus a weekly fee of $15 for the group only and $25 for both the group and the weekly training meeting. When you have completed requirements for graduation (84 consecutive days without sexual misbehavior and 28 consecutive perfect days of MAN PoWeR target behaviors), participation in both groups becomes free of charge. Signature Date Signature Date

4 Eternal Warriors Men of Moroni History of Lost Battles (To be filled out privately by the participant.) Your name: Your age now: Mr. M = Masturbation Mr. P = Pornography 1) Which of the two have you struggled with the most? 2) At what age were you first introduced to Mr. M? 3) Did you (A) discover it on your own, or (B) did someone teach you? If (B), who was it?. 4) At what age did Mr. M s visits become regular? 5) At what age was Mr. M the worst? 6) At that time, how often (on average) was it? Per day per week per month 7) What is the longest you have gone without it since that age? 8) What has been your pattern for the last 3 months? Clusters or Steady? -Clusters - How many days in a cluster of lost battles? How many good days in between? -Steady How often (on average) per day per week per month 9) At what age were you first introduced to Mr. P? 10) Did you (A) discover it on your own, or (B) did someone teach you? If (B), who was it?. 11) At what age did Mr. P s visits become regular? 12) At what age was Mr. P the worst? 13) At that time, how often (on average) was it? Per day per week per month 14) What is the longest you have gone without it since that age? 15) What has been your pattern for the last 3 months? Clusters or Steady? 16) -Clusters - How many days in a cluster of lost battles? How many good days in between? 17) -Steady How often (on average) per day per week per month 18) What is the primary source of Mr. P? 19) What type of Mr. P do you view?

5 NOTICE OF PRIVACY PRACTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REIEW IT CAREFULLY. We are providing you with this notice: WE are required by a federal law known as the Health Insurance Portability and Accountability Act (HIPAA) to give you this Notice. This notice will tell you about the ways in which we may disclose health information about you and will describe your rights and our obligations regarding the use and disclosure of that information. Your Health Information This notice applies to the information and records we have about your health, health status, and the health care services you receive from Life Changing Services. This information and these records relate primarily to counseling services you have received from us. How We May Use and Disclose Health Information about You For Treatment We may use and disclose health information about you so that we can be paid by you, an insurance company, or another party, including current or future bishops if they are paying any portion of the fee for the services we provide to you. For example, we may need to give your insurance company information about our services to you so the company will pay us for these services. For Agency Operations We may use and disclose health information about you in order to run our office and make sure that you and our other clients receive quality care. For example, we may use your health information to evaluate the performance of our staff or to contact you to remind you of your appointments. Please notify us in writing if you do not want us to contact you to remind you of your appointments. Special Situations We may use or disclose your health information without your permission for several reasons. These reasons include: Disclosing your health information when we believe that disclosure is necessary to prevent a serious threat to your health and safety or the health and safety of another person. Disclosing your health information as required by federal, state or local law. Disclosing your health information as required by law to prevent injury or suspected abuse or neglect. Disclosing your health information in response to a court order, subpoena, warrant, summons or similar process.

6 Other Uses and Disclosures of Health Information Except where otherwise required or authorized by law, we will not use or disclose your health information for any purpose without your written authorization. If you authorize us to use or disclose health information about you, you may revoke your authorization, in writing at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization, but we cannot take back any uses or disclosures we have already made with your permission. Your Rights Regarding Your Health Information You have the following rights with regard to your health information: You may inspect or copy your health information, with certain exceptions. If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You may obtain an accounting of our disclosures of your health information. This is a list of all of our disclosures of your health information for purposes other than treatment, payment and health care operations. You have the right to request that we restrict or limit our use or disclosure of your health information to only treatment, payment or health care operations. We are not required to comply with your request. You may request that we communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work. You have the right to receive a paper copy of this notice. If you want to exercise any of these rights, please contact the agency director, in writing, at the office where you are receiving counseling. Changes to This Notice We have the right to change this notice. If we do so, the new notice will apply to the health information we may already have about you and to the health information that we receive in the future. We are required to abide by the most current notice that is in effect. We will post a summary of the most current information in our office. You are entitled to receive a copy of the most current notice. Complaints If you believe your privacy has been violated, you may file a complaint with our office or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint. This notice is effective as of April 1, 2003 I have read and understood the above Notice of Privacy Practice. Name Signature Date

PATIENT INFORMATION. Name: Date of Birth: Age: Last name First Middle I. Home Address: City: State/Zip: Home Phone: Cell Phone:

PATIENT INFORMATION. Name: Date of Birth: Age: Last name First Middle I. Home Address: City: State/Zip: Home Phone: Cell Phone: THE ELITE LASER VEIN CENTER MICHAEL F. RICHMAN, M.D.,F.A.C.S. Date: PATIENT INFORMATION Name: Date of Birth: Age: Last name First Middle I Soc. Sec. #: Driver License#: Home Address: City: State/Zip: Home