New Client Intake Consent and Agreement

New Client Intake Consent and Agreement

Telehealth Services
Client Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Parent/Guardian Name

First Name Last Name
I/We hereby certify that I/We have received an orientation to Red Road Counseling Services, LLC. I have received orientation material and copies relating to my services and fully understand the material. My orientation included the following and was explained to me in a manner that I can understand:

Client Bill of Rights

Confidentiality of Client Records

Client Grievance Procedure

Therapeutic Model & Description of Treatment Modality and Services

HIPAA/Notice of Privacy Practice

Program Handbook

Fee Schedule and Financial Arrangements

Services Available

Treatment Goals/Objectives

Emergency Procedures

Availability of Crisis Intervention Services (including the telephone number where staff can always be reached)
Initials *
I/We hereby consent to voluntary admission to the services of Red Road Counseling Services, LLC.
Initials *
I/We hereby consent to receive Telehealth services and have completed the Informed Consent for Telehealth Services.
Initials *
I/We hereby consent to participate in a survey regarding the services I receive.
Initials *
I/We participated in the development of the Transition/Aftercare Plan and agree to the information listed.
Initials *
I/We participated actively participated in the development of the service plan and understand the treatment goals and objectives listed, and provided a statement in regards to both.
Initials *
Client Signature (14 or older) *
Date *

Month Day Year
Date
Parent/Guardian Signature *
Date *

Month Day Year
Date
Date

Month Day Year
Date
Should be Empty: