As the parent or legal guardian with the authority to consent on behalf of the consumer named above, I hereby give my consent to receive behavioral health treatment (which may include services, supports, and/or medication) for the above-named Consumer. Services may include one or more of the following:
1. Diagnostic Evaluation (with or w/out medical) and Diagnostic Evaluation Update
2. Community Psychiatric Service Treatment (CPST)
3. Psychotherapy [Individual, Family, Group, Crisis)
4. Psychoeducation Support Services (Therapeutic Behavioral Services, Psychosocial Rehabilitation)
5. Substance Use Disorder Assessment and ASAM Level of Care
6. Substance Use Disorder Services (Case Management; Individual Counseling; Group)
7. Intensive Outpatient Treatment
8. Pharmacologic Management Services 9. Laboratory Analysis
I understand that all information shared with service providers at The Bridges Core Services Agency is confidential and no information will be released without my consent. During the course of treatment at The Bridges Core Services Agency, it may be necessary for my service provider to communicate with providers at The Bridges Core Services Agency. While written authorization will not be requested, prior to any discussion with The Bridges Core Services Agency providers, I understand that only the provider will discuss all communications with me. In all other circumstances, consent to release information is given through written authorization. Verbal consent for a limited release of information may be necessary for special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which include the following:
A.When there is a risk of imminent danger to myself or to another person, the service provider is ethically 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 provider is legally required to take steps to protect the child and to inform the proper authorities.
C. When a valid court order is issued for medical records, the provider and the agency are bound by law to comply with such requests.
If I have any questions regarding this consent form or about the services offered at the Bridges Core Services Agency, I may discuss them with my provider or the Clinical Manager. have read and understand the above. I consent to receive the treatment offered to me by the Bridges Core Services Agency. I understand that may stop treatment at any time.
The consent/or treatment process has been thoroughly explained to me and I understand that I may stop treatment at any time.