BH Agreement between Outpatient and Patient or Parent/Guardian

BEHAVIORAL HEALTH DEPT.

Agreement Between Outpatient and Patient or Parent/Guardian
Patient Name: *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Phone:

Area Code Phone Number
Additional Parent/Guardian Phone:

Area Code Phone Number
Is the person who will transport the client to and from appoinments the same as the parent/guardian above?

Yes No
Person who will transport the client to and from appointments:

First Name Last Name
Please read and check off the following to indicate understanding: *

I understand that there are not any medical procedures conducted by the behavioral health staff. Should medical assistance be required I will assume responsibility for seeking such treatment. Should an emergency occur, an ambulance will be called for me. I understand that the only medications administered by the behavioral health staff are long-term, injectable psychiatric medications that are brought to the appointment by the person receiving the injection. I have been informed that the Patient Rights and Responsibilities are posted throughout the department and are available in writing by request. I have been instructed to contact the site manager if I have any questions. I have been given a written copy of the Notice of Privacy Practices. I understand that all staff are mandated reporters and are required to report suspected child abuse and neglect (as described by CT statutes 17a-28; 17a-101; 46b-120). I understand that my confidentiality may be waived if I express an intention to harm myself, harm another, commit a crime, or if I am experiencing child or elder abuse, or am gravely disabled. Information will be released after signing a release of information form. If I sign a release of information form, I will do so of my own free will. The release will expire within one year; however, I may withdraw the release at anytime without prejudice. I have been given information about other Generations services by Behavioral Health Department staff. I understand that to file a complaint I must register my complaint in writing with the Behavioral Health Site Manager or the Privacy Officer. A complaint form will be provided to me by Behavioral Health staff when requested. I understand that my complaint will be investigated within five days, and I will receive a response within 30 days. I understand that I am responsible for payment of my session at the time of each session. If I have made payment arrangements, I understand that I am responsible to make such payments. I understand the fee which I will be charged for each session. I have been provided with the business hours of the behavioral health clinic at Generations. I understand that there are not any medications prescribed after business hours, although I may contact a clinician if I require assistance by dialing 860-450-0585. I also understand that if I am experiencing an emergency, I should call 911 or go to the closest hospital emergency room. I understand that when I arrive for my appointment I must check in at the front desk and make a payment (if applicable), and when I am leaving I must check out at the front desk to make a future appointment. I understand that if I need to cancel an appointment after hours, I will leave the information with the answering service at 860-450-0585. All of the above information was reviewed with me by clinic staff.
Patient signature (age 5 and older must sign)

Clear
Date

Month Day Year
Date
Parent /Guardian Signature

Clear
Date

Month Day Year
Date
Generations Family Health Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Generations does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

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BEHAVIORAL HEALTH DEPT.