I understand that as a patient at the Community Health Center of Center of Central Wyoming (CHCCW) I am eligible to receive a range of services, including Behavioral Health. The type and extent of Behavioral Health services that I will receive will be determined following an initial assessment and thorough discussion with me and my parent/guardian. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

I understand that all information shared with the clinicians and professional staff at CHCCW is confidential and that no information will be released without my written consent. During treatment at CHCCW, it may be necessary for my clinician to communicate with CHCCW providers who are also a part of my care team.

 I understand that all information shared with the clinicians and professional staff at CHCCW is confidential and that no information will be released without my written consent. During treatment at CHCCW, it may be necessary for my clinician to communicate with CHCCW providers who are also a part of my care team.

 I understand that my clinician will discuss communications had with other CHCCW clinicians or professional staff with me. In all other circumstances, consent to release information is given through written authorization.

I further understand that there are specific and limited exceptions to this confidentiality which include the following:
A. When there is risk of imminent danger to myself or to another person, the clinician is ethically and legally bound to take necessary steps to prevent such danger.

B. When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the clinician or provider is legally required to take steps to protect the vulnerable person and to inform the proper authorities.

C. When a valid court order is issued for medical records, the clinician and the agency are bound by law to comply with such requests.

I understand that while psychotherapy and/or medication management, may provide significant benefits, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings or may lead to the recall of troubling memories. Medications may have unwanted side effects. Medication management can be complex and may require continual monitoring to control or prevent unwanted side effects.

I understand that I am expected to make every attempt to pay any payment due, co-payment, or coinsurance amount at the time of service, but understand that an inability to pay will never prevent me from being treated at CHCCW. 

I understand that I, staff and other patients all have the right to a safe environment and that any abusive or threatening behavior will not be tolerated and will be cause for termination of services. If I have any questions regarding this consent form or about the services offered at CHCCW, I may discuss them with my clinician.

If I have any questions regarding this consent form or about the services offered at CHCCW, I may discuss them with my clinician. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by CHCCW. I understand that I may stop treatment at any time.