CONSENT FOR TREATMENT

CONSENT FOR TREATMENT
Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Consent for Services, Emergency, & Transportation

I apply for and consent to such medical, psychiatric and / or other service as the staff of CLAYS may indicate, including diagnostic tests and counseling. I agree to co-operate in the implementation of the services. I have been informed that statistical information concerning my treatment will be submitted to Department of Health & Human Services. I understand and agree that in some emergency situations the agency may have to disclose some information in order to assist with a crisis or emergency incident. I also agree that the agency will not be held to any litigation if I accept transportation from an agency worker.
Family Involvement Consent / Denial
*

I consent to have the family members listed below involved in the planning and delivery of the services that I shall be receiving from CLAYS for this period of service. I understand that, without this consent, the agency’s employees will not be allowed even to acknowledge to any family member that I am a consumer of their services. I do not consent to have family members involved in the planning or delivery of the services I shall be receiving in this period of service.
1) Family Members To Be Involved:

First Name Last Name
Phone Number:

Area Code Phone Number
Relationship:
2) Family Members To Be Involved:

First Name Last Name
Phone Number:

Area Code Phone Number
Relationship:
(If parent or legal guardian is indicated under "Relationship" then that individual may sign future forms as representative of a child consumer)
Follow-up Contact Consent
I consent to staff of CLAYS contacting me within 90 days of the termination of this period of service, in order to collect information on the outcomes of that service. I further consent to such contact being made through the following persons nominated by me:
I do not consent to follow-up contact.
Contact Person 1:

First Name Last Name
Phone Number:

Area Code Phone Number
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Person 2:

First Name Last Name
Phone Number:

Area Code Phone Number
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
*Consent will expire after 1 year from signature date. Must be renewed every year.
Signature of Consumer/ Guardian: *

Clear
Date: *

Month Day Year
Date
Should be Empty:

CONSENT FOR TREATMENT

Family Involvement Consent / Denial

Follow-up Contact Consent