Ravenwood Health is committed to caring for the whole person. Becausephysical and emotional problems often go together, we provide integrated
behavioral health (BH) and primary care (PC) services. We believe in our
providers working together as a team to support your mental, emotional, and
physical health. With your consent, our clinicians share information as needed to
coordinate care, reduce duplication, and ensure you receive the best possible
treatment for your overall well-being. Ravenwood Health patients may be referred
to providers from other health care specialties within or outside of the Ravenwood
Health treatment team.

To assist with case coordination and facilitate communication of treatment
concerns, the treatment teams participate in clinical supervision and peer
consultations and may be discussing your case in treatment team meetings.

Ravenwood Health BH - In general, the benefits of therapy may include
increased insight, improvement in self-esteem, improvement in interpersonal
relationships, relief of symptoms including decreased anxiety and/or depression
and improvement in your ability to maintain your daily level of functioning.
Specific problem areas/needs and therapeutic goals will be addressed in your
Individual Treatment Plan. Due to the sensitive nature of an individual's therapy,
it is possible that therapy may provide a temporary increase in you or your
dependent's negative symptoms or stress level and there is no guarantee that
symptoms will be reduced and/or eliminated.

Diagnostic assessment, which may include, formal psychological testing, is an
important aspect of your or your dependent's treatment to aid in increasing
knowledge of your or your dependent's personality and/or intellectual functioning
as well as an aid in your or your dependent's progress in therapy.

Your consent may permit the disclosure of information to third parties to make
decisions that could have a significant effect on your or your dependent's life.
Third parties may include the courts, the Department of Job and Family Services,
the Bureau of Disability, Ohio Worker's Compensation, insurance companies,
county boards, OhioMHAS/Ohio Department of Behavioral Health, accrediting
bodies...Information may be released for the purpose of payment or where we
are required to share certain data for accreditation purposes.

Ravenwood Health (RH) is a mandatory reporter and the following disclosures do
not require authorization: 1) to avert imminent harm to client or others, as per
duty to protect statute; 2) as required by law (e.g. child/elder, abuse/neglect
reporting); 3) pursuant to a court order; 4) when defending legal action brought by
a client.

By signing this Informed Consent for Treatment form I hereby consent to the
following:

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I authorize the staff of Ravenwood Health to use any or all of those procedures
and treatments customarily employed in behavioral health facilities in the
treatment of psychiatric, mental health and emotional disorders and alcohol and
drug addiction treatment (customary care may include psychological methods
such as counseling and psychotherapy, random urine drug screens, evaluations
and aftercare) in order to provide care and treatment.

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I acknowledge that I have received an explanation of risks and benefits of each
proposed treatment, of alternate treatments and of no treatment. I understand
that if I am discharged, this may be an indication of a need for a different kind of
treatment

I understand that Ravenwood Health is integrated health care agency and has a
combined medical and behavioral health record.

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If, in the course of my treatment, psychiatric and/or medication and/or specialized
procedures are necessary, a separate consent form will be required from me at
that time. These special procedures include any unusual or hazardous treatment
procedures. I understand that it is dangerous to use drugs and/or alcohol if I am
taking psychotropic medications. If I receive psychiatric care, I agree to follow the
recommendations of both my therapist and the doctor.

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I consent to receive mental and physical health services. I consent to receive
drug and alcohol services, which may include observed random drug screens. I
have been informed that the Medical Director may sign an order for drug screens
to be done at this agency, should an order be signed a copy of the order is
available to me upon request.

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If Parent, I consent for my dependent, named on this form, to receive mental and
physical health services. I consent for my dependent, named on this form, to
receive drug and alcohol services, which may include observed random drug
screens.

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If Guardian, As Guardian, I am consenting to the dependent named on this form
to receive mental and physical health services. As Guardian, I am consenting to
the client named on this form to receive drug and alcohol services, which may
include observed random drug screens.

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I have received a copy and explanation of the Client Rights and Grievance
Procedures according to the Ohio MHAS and the Joint Commission.

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I have been informed of the HIPAA and Federal Confidentiality Laws and
Regulations regarding the confidentiality of alcohol and drug abuse information
and client records. I acknowledge receipt of a written summary regarding the
above.

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I understand that Ravenwood Health may release information and/or allow
access to health information with affiliated businesses who mutually serve our
clients. Access will be permitted only for those businesses with a current
business agreement with Ravenwood Health meeting HIPAA requirements.

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I have been advised of Ravenwood Health's (RH) NO SHOW/CANCELLATION
Policy: Two or more no shows/cancellations may result in services being
discontinued. I am aware that Copeline/988 and Emergency Services are still
available. I understand that regular attendance and participation in sessions
increases the likelihood that services will be effective.

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I understand that I may be contacted by an appointment reminder service
regarding my scheduled appointments at the agency by phone or text. I
understand I may incur charges for data and/or text usage by my cell phone
service provider. I will inform the agency if I choose to opt out of this reminder
service

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I understand that if I or my dependent is treated by a non-independently licensed
clinician, he or she will be supervised by an independently licensed therapist or
psychologist. This may include clinicians I or my dependent have not met or
clinicians working within a group setting.

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Heath Information Exchange
Ravenwood endorses, supports, and participates in electronic Health Information
Exchange (HIE) as a means to improve the quality of your health and healthcare
experience. HIE provides us with a way to securely and efficiently share patients'
clinical information electronically with other physicians and health care providers
that participate in the HIE network. Using HIE helps your health care providers to
more effectively share information and provide you with better care. The HIE also
enables emergency medical personnel and other providers who participate in the
program and who are treating you, to have immediate access to your medical
data that may be critical for your care. Making your health information available to
your health care providers through the HIE can also help reduce your costs by
eliminating unnecessary duplication of tests and procedures. However, you may
choose to opt-out of participation in the HIE, or cancel an opt-out choice, at any
time by completing the appropriate form which will be provided upon your
request.

The organization supports and uses and participates in HIE, which is a
confidential, computerized, system that collects and consolidates vaccination
data for Ohioans of all ages and provides tools for designing and sustaining
effective immunization strategies to prevent disease and reduce healthcare costs.
Information in the HIE system can be released only to individuals; individual's
parent/legal guardian; individual's healthcare provider; a school or child care
center where the individual is enrolled; health insurers if financially responsible
for immunizations; healthcare organizations; Department of Health Care Policy
and Financing for individuals enrolled in Medicaid. You may choose to opt-out of
participation in the HIE system or cancel an opt-out choice. This notification must
be in writing and may be presented at any time

I have been informed that Ravenwood Health participates in the Clinisync Health
Information Exchange system. Through the system clients are automatically
enrolled for us to be able to receive notification of hospitalizations and emergency
room visits through the Clinisync Notify system. If you would like to opt out of the
system please let staff know and we will get you the forms to opt out. ***
currently only this paragraph****

External Medical Record

Ravenwood Health participates in access to external medical records as well as
participates in utilizing external electronic health records for the purpose of
continuity of care to specialists as needed. I hereby authorize Ravenwood Health
to access my medical records externally through various contracted platforms.

If you choose to participate in Ravenwood Health's Primary Care Clinic/ program
you are consenting to the following: I hereby voluntarily consent to outpatient
care from Ravenwood Health encompassing routine diagnostic procedures,
examination, and medical treatment including (but not limited to) routine
laboratory work and administration of medications as prescribed by the Providers.
I further consent to the performance of those diagnostic procedures,
examinations, and rendering of medical treatment by the Primary Care Clinic at
Ravenwood Health medical Providers and staff, as is necessary in the medical
staff's judgment. I understand that during the course of treatment, health care
workers may be exposed to the patient's blood and/or body fluids increasing their
risk of contracting Hepatitis B, Hepatitis C, and/or HIV. In the event an exposure
occurs, I understand the need for testing for these diseases and I agree to such
testing of myself to promote the health and welfare of the health care worker. I
understand that this consent will be valid and remain in effect as long as I attendthe clinic.

Communication

I have been informed that Ravenwood Health's evaluation team may contact me
to participate in random, confidential, voluntary interviews for research purposes.
I understand I may decline to participate at the time of contact by the evaluation
team and participation or non-participation will have no impact on my services.

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I authorize Ravenwood Health (RH) and/any entity authorized by RH, including
those using automated dialing systems, automated messages, email, text
messaging and/or other electronic communications to contact me for any reason
by using any telephone number, email address, and/or mailing address
associated with my account

I authorize Ravenwood Health (RH) to share any information provided to RH
including, but not limited to: name, address, financial information, and service
history for laboratory and pharmacy purposes.

Informed Consent Telehealth
Ravenwood Health (RH) is committed to provide timely, high quality, clinical
services to its clients. To meet this aim, Ravenwood Health will offer, when
clinically appropriate and feasible, interactive, HIPPA, and 42CFR compliant,
Telehealth and interactive video conferencing services.
Electronic systems used will incorporate network and software security protocols
to protect the confidentiality of patient identification and imaging data and will
include measured to safeguard to data and to ensure it's integrity against
intentional or unintentional corruption.

Limitations of Telehealth
When consenting to treatment via interactive video conferencing, it is important to
consider limitations and potential risks of this services delivery method, which
includes the following:

1. - Audiovisual equipment may experience technical difficulties.

2. - While every precaution is taken to secure patient data and maintain
confidentiality, the nature of electronic appointments results in additional
exposure to risk of security breaches

3. - Your provider will screen for appropriateness to receive services via distance methods and will regularly assess whether electronic services delivery is the most effective method of treatment. At any point should your provider feel the
distance methods are no longer appropriate, you may be required to transfer to
an in-office provider

4. - Certain medications may not be prescribed via telehealth services, and may
require in person visits

By signing this form, I understand the following:

1. I understand that the laws protecting privacy and the confidentiality of
protected health information also apply to Telehealth services, and that no
information obtained in the use of Telehealth services which identifies me will be
disclosed to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use
of Telehealth services during my care at any time, without affecting my right to
future care or treatment.

3. I understand that a variety of alternative methods of treatment may be
available to me, and that I may choose one or more of these at any time.

4. I understand the risks and benefits associated with receiving services via
interactive video conferencing.

5. I understand that Ravenwood Health's No Show/Cancellation Policy applies to
Telehealth services.

AI Assisted Documentation
Ravenwood Health has some staff that have the opportunity to use Artificial
Intelligence (AI) tools to enhance client care. These tools may assist clinicians
with documentation, session insights, and therapeutic support. The goal is to
improve service quality, reduce administrative burden, and support more
personalized care.

If you choose to participate:
AI tools may be used during your sessions to assist the staff allowing staff
to be more present
All staff remain fully responsible for your care and will review all AI
generated content.

Confidentiality and Data Protection
Your privacy is a top priority. All data processed by AI tools will be handled
in accordance with HIPAA and Ravenwood Health's privacy policies.
No identifiable information will be shared outside Ravenwood Health.
AI tools used in this program are secure and compliant with healthcare
data standards.

Client Rights
As a participant in this program you have the following rights:
Right to Informed Consent: You have the right to receive clear,
understandable information about how AI will be used in your care.
Right to Decline or Withdraw: You may decline to participate or withdraw
your consent at any time without penalty or impact on your access to services.
Right to Ask Questions: You may ask questions at any time about the AI
tools, how they work, and how your data is used.
Right to Privacy: You have the right to confidentiality and protection of your
personal health information.
Right to Equitable Care: You will receive the same quality of care whether
or not you choose to allow the use of AI tools

Voluntary Participation
Participation is completely voluntary. You may decline or withdraw your consent
at any time without affecting your access to services. If you choose not to
participate, your sessions will continue as usual without AI involvement.
Risks and Benefits

Potential Benefits: Improved session documentation enhanced therapeutic
insights, and more efficient care.
Potential Risks: Discomfort with AI involvement or concerns about data
use. Ravenwood Health will address any concerns promptly.

By checking the box below I am consenting to the use of AI tools during my sessions at Ravenwwod Health.

Student Involvement & Consent
I understand that Ravenwood Health is a clinical training site and that supervised
students may observe or participate in my behavioral health and substance use
treatment.

Choice & Access:
My consent is voluntary. I may accept or decline student involvement at the start
of any encounter without affecting my quality of care or eligibility for services.

Confidentiality:
All students are bound by HIPAA and 42 CFR Part 2. My records are protected by
federal non-redisclosure laws, and students may not share my identifying
information without my express written consent.

Revocation:
I may revoke this consent at any time, except for actions already taken.

By signing below I am consenting to receive treatment at Ravenwood Health.

Revocation

If client and/or parent/guardian wish to refuse or revoke this consent for
treatment, please print the document and manually sign and date. The document
will then be scanned into the system in the "Revoked Consent for Tx" folder