Time*

Hour Minutes

AM/PM Option

Client Name:*

First NameLast Name

Client Insurance or SoonerCare/Medicaid ID #:*

I/We (Client/Guardian) have participated in the development of this treatment plan, diagnosis, goals, and/or objectives and have the following response:*

Do you agree with this treatment plan?*

YesNo

TELEMEDICINE CLIENT CONSENT
I, hereby give my consent to LFS Counseling Therapist/Provider, to complete Intake, as well as provide any subsequent treatment via telemedicine and/or videoconference session based on the Intake results for Behavioral/Mental Health. This agreement authorizes the electronic transmission of my medical/personal information and/or video-conference session so that it can be viewed by my counselor and /or other persons involved in my mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small]. I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to LFS Counseling providing health care services to me via telemedicine. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to be seen in person. I understand that medical records of telemedicine services will be kept at LFS Counseling’s Administration Site. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine and that information will not be released without signed consent. Furthermore, I understand that all audio and video telecommunications are compliant with the Health Insurance Portability and Accountability Act (HIPAA) and all laws and policies that protect privacy and the confidentiality of medical information. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I understand that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I may revoke my consent orally or in writing at any time by contacting LFS Counseling or my counselor directly. As long as this consent is in force (has not been revoked) LFS Counseling may provide health care services to me via telemedicine without the need for me to sign another consent form.

Do you consent to Telemedicine Services?*

YesNo

Right to Name a Treatment Advocate (For adults 18 years or older)
A "Treatment Advocate" is a family member or other concerned individual designated by a consumer to participate in treatment and discharge planning, and acts in the best interest of and serves as an advocate for the consumer.

As an adult client of LFS Counseling, you have the right to designate a family member or other concerned individual as a Treatment Advocate. Your Treatment Advocate should act in your best interest at all times. You may change or revoke the designation of a Treatment Advocate at any time and for any reason. Your Treatment Advocate may participate in your treatment planning and discharge planning to the extent that you consent to and as permitted by law. 450:-27-5-44

Having reviewed the Treatment Advocate Form, would you like to change the Treatment Advocate Form? (For adults 18 years or older ONLY)*

NoYes

Is the client able to sign for self?*

YesNo

If Client is Unable to sign, please contact our Administrative Office.*

Where do I need to sign?*

If the Client is a Minor, and age 14 or older - BOTH Client and Guardian are required to sign.If the Client is under the age of 14 a client signature is not needed. The Guardian will sign in the Guardian Signature box below.If you are the Client age 18 or older please sign in the Client Signature box below.

Client Signature, 14 or older: (If Not Required, Please Type N/A)

Please sign your first and last name as clearly and as legibly as possible. If the signature is not legible, this form will be returned for correction and could delay services

Date:*

Date

Parent/Guardian Signature (If None, type N/A): *

Please sign your first and last name as clearly and as legibly as possible. If the signature is not legible, this form will be returned for correction and could delay services.

Relationship to client, if Applicable (If None, type N/A):*

Date:*

Date

Witness/T.A. Signature, if applicable: (If None, type N/A)*

Please sign your first and last name as clearly and as legibly as possible. If the signature is not legible, this form will be returned for correction and could delay services.

Date:*

Date

For Office Use Only:

Date Treatment Plan was completed in Milan/Simple Practice:

Type of Service, Frequency, and Printed Name, Degree, and License:
(Example - Individual Psychotherapy, 1-2x Weekly, John Smith MA, LPC)

Please ensure the accuracy of this information! List each service, frequency of sessions, and name, degree and license. Incorrect or missing information will void the signature page and may cause delays in billing.

LBHP Therapist Signature, Degree and License:

Responsible Licensed Therapist Signature, Degree and License&#13;&#10;&#13;&#10;&#13;&#10;&#13;&#10;&#13;&#10;

Please sign your first and last name as clearly and as legibly as possible. If the signature is not legible, this form will be returned for correction and could delay services. LBHP signature indicates completion of the face to face assessment. Furthermore, medical necessity and appropriate level of care, including the evaluation of all pertinent information by the other service rendering therapists and the client, have also been reviewed for this service plan.

Candidate or Under Supervision Signature, Degree, and License:

Type "N/A" if Not Applicable

Please sign your first and last name as clearly and as legibly as possible. If the signature is not legible, this form will be returned for correction and could delay services. LBHP signature indicates completion of the face to face assessment. Furthermore, medical necessity and appropriate level of care, including the evaluation of all pertinent information by the other service rendering therapists and the client, have also been reviewed for this service plan.

Physician Signature, If applicable:

Type "N/A" if Not Applicable

Case Manager Signature:

Type "None" if None

LFS Signature Page (Client)

For Office Use Only: