• CONSENT FOR TREATMENT

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  •                              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

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  • (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

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  • *Consent will expire after 1 year from signature date. Must be renewed every year.

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