Consent for Services:
I, We hereby authorize psychological testing, counseling, and/or education by any therapist and/or qualified mental health provider authorized by Variety Care. I/We understand that consent is given before any specific diagnosis or services are required.
I/We agree to be actively involved in the treatment plan as prescribed by Variety Care treatment team while I/We receive services. I/We understand that included in this treatment plan may be my/our involvement in regular family, individual, or group counseling sessions.understand that included in this treatment plan may be my/our involvement in regular family, individual, or group counseling sessions.
The assessment process is used and information is collected to result in individualized and goal-oriented, person-centered planning.
Variety Care upholds all guidelines of State, Federal, Local and HIPAA requirements to ensure the privacy of your information.
Information is collected as part of the service process for assessment, intervention planning and supervision purposes. Most of the information will be recorded in written or electronic form and as appropriate. All information is kept confidential and cannot be released without your written permission except for special situations which include:
A "duty to warn" ethic allows a clinician to break confidentiality when imminent danger exists to the client and/or others;
Under special circumstances, the court may subpoena a client's records and may order a clinician to give testimony during a court hearing;
Suspicion of child abuse and/or neglect.
I have been informed of Variety Care's services including the facility's policy regarding confidentiality. I have read the information presented to me and I've been given an opportunity to have any questions I might have answered by a staff person.