I,

agree to:

, and to contact Beautiful Minds Medical staff if unable to attend.

2. I agree to provide my own transportation to and from the facility. I agree to arrive on time and leave at the end of the program day. I will inform staff of any need to leave early and notify staff in advance of any anticipated absences. Frequent absences or leaving group/activities early on a regular basis will result in review of my continued participation in the program.

3. Cooperate with staff and participate, to the best of my ability, in all activities and group scheduled for me. Noncompliance  with the treatment recommendations may result in failure to meet treatment goals and may also result in your being  referred to a higher or lower level of care or otherwise discharged from the program. 

4. Not use or possess street drugs or alcohol before or during program hours.

5. Refrain from making physical or verbal threats to people or property, such as name calling, put-downs, threating with objects, threatening bodily harm or property destruction.

6. Remain in the facility during program hours unless other arrangements have been made with staff.

7. My rights as a patient have been described to me by staff. Failure to comply with the rules will result in review of treatment with staff, suspension and/or discharge from the program.

8. Refrain from assaultive behavior toward others or destructive behavior toward myself, for example, cutting myself or overdosing on medication. If I am at risk of hurting myself or others during the program attendance I agree to tell staff.

9. Hydrotherapy and massage are a part of our whole-person approach to mental health treatment, addressing mind, body and spirit. You will receive several hydrotherapy and massage treatments during the program.

10. I,

, hereby acknowledge that I have received this Notice of Privacy Practices. Within these guidelines, at Beautiful Minds Medical, specifically there are five instances in which your right to privacy will be set aside:

A. Your therapist is required by law to report if any participant in therapy, specifically or vaguely disclose(s) information possibly indicating current or past abuse or neglect of a child, dependent adult, or elder.

B. Your therapist must notify the local authorities and/or the person(s) in danger if your therapist believes, from information that you disclose, that you are of danger to yourself or to someone else.

C. During court proceedings, the Judge’s ruling supersedes your right to confidentiality. The attorney may subpoena your records, take your therapist’s deposition, have your therapist appear in court, or all three. Your therapist must break confidentiality if the Judge makes such an order.

D. Beautiful Minds Medical works within a Treatment Team model to provide an integrated approach to the overall needs of the client. In accordance with this model, information and behavior during group and/or individual and/or family session may be shared with the Beautiful Minds Medical Treatment Team (i.e., Psychiatrist, Nurse, Therapist, Life Coach, and IOP Coordinator). The information is shared for the purpose of treatment planning to best meet your therapeutic needs.

 

If I am at risk of hurting myself or others while away from the program, I will call: