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Same day admissions possible - Most insurance accepted

Telehealth Application

Serenity Lane Treatment Center
Home Telehealth Application


Step 1 of 15 - Welcome to Serenity Lane Telehealth

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  • Welcome to Serenity Lane Telehealth!

    This orientation should include all of the information for you to get started. Please review this packet in full, review the Patient Handbook, complete and return all attached forms. If you have any questions, please contact your primary counselor.

    What is Telehealth?

    Telehealth is the delivery of healthcare services when the healthcare provider and patient are not in the same physical location through the use of technology. Providers may include primary care practitioners, mental health specialists and counselors. Electronically transmitted information is used for therapy, follow‐up and/or patient education, and may include interactive audio, video, and/or data communications. Telehealth has many benefits, including improved access to care by enabling a patient to remain at home or a remote site for care.

    Due to COVID‐19, the Department of Health and Human Services (HHS) and SAMHSA (Substance Abuse and Mental Health Services Administration) have lifted restrictions previously placed on interactive electronic systems used for communications for Telehealth (such as Skype for Business, etc.). The interactive electronic systems used may not protect the confidentiality of patient identification and imaging data and measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

  • Telehealth Packet

    • Zoom for Telehealth Instructions: Please review this attached document carefully and ask your counselor if you have any questions.

    • Telehealth Informed Consent: Please review this attached document carefully and ask your counselor if you have any questions.

    • Consent Packet: Please review these attached documents carefully and ask your counselor if you have any questions.

      A. Acknowledgement and Consent for Screening, Assessment and Treatment
      B. Abstinence Focused/ Medication Assisted Treatment
      C. Acknowledgement of Risks Associated with Leaving Treatment Early
      D. COVID‐19 Notification, Disclosure and Consent
      E. Notice of Privacy Practices

    • Release of Information (ROI) Form for Emergency Contact: This person will only be contact for emergency purposes and will not receive your treatment information unless you fill out a full ROI.

    • Release of Information (ROI) Form: A Release of information is a statement signed by you authorizing us to give information about your treatment to others that you identify. Please fill an ROI out for each person/ organization you would like us to share your information with.

    • Blue Flag Data Request: Serenity Lane offers a service for patients when employers or other referring agencies need feedback regarding evaluation results and compliance with treatment recommendations. This monitoring service is what we refer to as our Blue Flag system. Serenity Lane will only provide this service when the patient requests it and signs an authorization to release information. The signed authorization will specify the types of information that the patient wants Serenity Lane to disclose. Typically, the information includes attendance and participation in treatment as well as showing good faith by completing a treatment plan. At other times, the agency may need the results of drug screens.

    • Medication Reconciliation: Please provide a list of all current medications, including over the counter. Serenity Lane's Medical Director may need to review your medications.

    • Patient Preferences and Goals Packet: These forms are to obtain additional information to help Serenity Lane make your safety, preferences and goals a priority while in our care. We want to work with you throughout treatment to create and update a Service Plan that focuses on helping you with problems you are experiencing as a result of substance use, as well as what you wish to accomplish while you are in our care.

    • Tour of Facility: Patient is utilizing telehealth services. No tour of facility necessary.

    • Please review the Patient Handbook (separate file). The following information is included:

      • Declaration for Mental Health Treatment opportunity;
      • Education regarding Advance Directives;
      • Description of individual rights and Grievance and Appeals policy;
      • Voter Registration opportunity;
      • Ways in which input can be given by patient;
      • Rules regarding confidentiality;
      • Care coordination;
      • After-hours hotlines
    • Financial Information (separate file):

      • Financial review including Terms of Admission (TOA).
      • Billing questions may be directed to Business Office at 1-800-826-9285

    By signing this document, I acknowledge that I have received and reviewed each of the documents and instructions listed above and that I consent to the terms in these documents. I understand that if I am not willing to consent to the terms in these documents, Serenity Lane will provide referrals to other treatment providers.

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Non-profit treatment centers for
alcohol and drug addictions.
Treatment facilities located in:

Coburg, Eugene, SE Portland, SW Portland, Salem, Albany, Bend, and Roseburg, OR