Use this form to give or take away your consent to share information about your child’s:

• Mental and behavioral health services. This will be referred to as “behavioral health”
  throughout this form.
• Diagnosis, referral, and treatment for an alcohol or substance use disorder. This will be referred
  to as “substance use disorder” throughout this form.

This information will be shared to help diagnose, treat, manage, and pay for your health needs.

Why This Form is Needed
When your child receives health care, their health care provider and health plan keep records about their health and the services they receive. This information becomes part of their medical record. Under state and federal laws, your child’s health care provider and health plan do not need your consent to share most types of your health information to treat your child, coordinate their care, or get paid for their care. But they may need consent to share your child’s behavioral health or substance use disorder records.

Instructions

• To give consent, fill out Sections 1, 2, 3, and 4.
• To take away consent, fill out Section 5.
• Sign the completed form, it will be sent electronically Washtenaw County Children’s Services. A copy will also be emailed to you at the email address you provide below.

Section 2: Who Can See Your Child's Information and How They Can Share It

Sharing Information Between Individuals and Organizations
Let us know who can see and share your child’s behavioral health and substance use disorder records. You should list the specific names of health care providers, health plans, family members, or others. They can only share your records with people or organizations listed below.

Section 4: Your Consent and Signature
Read the statements below, then sign and date the form.
By signing this form below, I understand:

• I am giving consent to share my child’s behavioral health and substance use disorder records.  This includes referrals and services for alcohol and substance use disorders, but other  information may also be shared.
• I do not have to fill out this form. If I do not fill it out, my child can still get treatment. But, without this form, Washtenaw County Children’s Services may not have all the information  needed to treat my child.
• My child’s records listed above in Section 3 will be shared to help diagnose, treat, manage, and  pay for their needs.
• My child’s records may be shared with the people or organizations as stated in Section 2.
• I can remove my consent to share my child’s behavioral health and substance use disorder records at any time. I understand that any records already shared because of past approval  cannot be taken back. I should tell all individuals and organizations listed on this form if I  remove my consent.
• I have read this form. Or it has been read to me in a language that I can understand. My  questions about this form have been answered. I can have a copy of this form.
• This signature is good for 1 year from the date signed. Or I can choose an earlier date or have it  end after the event or condition listed below. (For example, at the end of my child’s  treatment.)

PSYCHIATRIC CONSULTATION FORM

I consent to my child’s participation in receiving a psychiatric consultation by mental health professionals at Washtenaw County Children’s Services for assessment and treatment recommendations.

1. I understand that following the provision of any services, information will be provided concerning each of the  following areas:
   1. The benefits and indications for any proposed treatment.
   2. The manner in which treatment will be administered
   3. Risks of side effects from medications (when applicable)
   4. Probable consequences of not receiving treatment
2. Information from my child’s assessment and/or treatment will be stored in a confidential medical record at  Washtenaw County Children’s Services, and I consent to disclosure for use by the parties I have indicated on the  accompanying Consent to Share Behavioral Health Information Form for continuity of my child’s care.  Information provided will be only be shared with the parties indicated on the Consent to Share Behavioral  Health Information form, except for in the following instances:
   1. if youth is deemed to present a danger to himself/herself or others;
   2. if concerns about possible abuse or neglect arise; or
   3. if a court order is issued to obtain records.
3. I have the right to withdraw my consent for evaluation and/or treatment of my child at any time by providing a written request to Washtenaw County Children’s Services.
4. This consent will expire 12 months from the date of signature, unless otherwise specified.

I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation. I also attest that I am the legal guardian and have the right to consent for the treatment of this child. I understand that I have the right to ask questions of my child’s service provider about the above information at any time.