Counseling Intake Form

Consent For Treatment
Consent for Services, Emergency, & Transportation
I apply for and consent to such medical, psychiatric and/or other service as the agency may indicate, including diagnostic tests and counseling. I agree to co-operate in the implementation of the services. I have been informed that statistical information concerning my treatment will be submitted to Department of Health & Human Services. I understand and agree that in some emergency situations the agency may have to disclose some information in order to assist with a crisis or emergency incident. I also agree that the agency will not be held to any litigation if I accept transportation from an agency worker.
Family Involvement Consent/Denial
I consent to have the family members listed below involved in the planning and delivery of the services that I shall be receiving from the agency for this period of service. I understand that, without this consent, the agency's employees will not be allowed even to acknowledge to any family member that I am a consumer of their services.
Family members to be involved:
Name
Relationship
Phone
Name
Relationship
Phone
If parent or legal guardian is indicated under "Relationship" then that individual may sign future forms as the representative of a child consumer.
I do not consent to have family members involved in the planning or delivery of the services I shall be receiving in this period of service.
Follow-up Contact Consent
I consent to the agency contacting me within 90 days of the termination of this period of service.
Contact Person 1
Phone
Address
Contact Person 2
Phone
Address
I do not consent to follow-up contact.
Signature of Patient: (If minor, Parent or Guardian)

Clear
Date

MonthDayYear
Date
*Consent will expire after 1 year from signature date. Must be renewed every year.

Agreement to Receive Electronic Communication
Patient Name
Date of Birth

MonthDayYear
Date
I agree that Venus Allen, LCSWA LCASA CMC and practice staff may communicate with me electronically at the email address below.

I am aware that there is some level of risk that third parties might be able to read unencrypted emails.

I am responsible for providing the practice any updates to my email address or phone number.

I can withdraw my consent to electronic communications by emailing vallen@cpcoalition.org or cpcoalition2@gmail.com, or calling 919.807.1090.

Crisis Number: 704.231.2859 (24/7)
Email
example@example.com
Phone
Patient/Parent Signature

Clear
Date

MonthDayYear
Date

Program Participant’s Rights and Responsibilities Acknowledgment
Every program participant of Venus Allen, LCSWA, LCASA, CMC, CJSOTS has human/civil/personal rights to be respected and honored. In addition, it is the responsibility of all program participants to act in a manner that respects the rights of others. Our agency is committed to the protection of individual rights and to providing services within an environment that is characterized by dignity and respect of all persons, and is responsive to the unique needs, abilities, and characteristics of each person served by the organization.

Program Participant Rights: As a participant in programming, you have the right to:
- Be fully informed about the course of your care and decisions that may affect your treatment
- Revoke your consent for treatment at any time
- Timely and accurate information to assist you in making sound decisions about your treatment
- Be fully involved as an active participant in decisions pertaining to your treatment
- Have an individual identified in writing that will direct and coordinate your treatment
- Request a change in individual directing and coordinating our treatment, if you so desire
- Receive services in an environment that is free of all forms of abuse, including, but not limited to, (a) financial abuse, (b) physical abuse and punishment, (c) sexual abuse and exploitation,(d) psychological abuse including humiliation, neglect, retaliation, threats and exploitation,and (e) all forms of seclusion and restraint
- Have information about your treatment and your confidentiality protected to the greatest extent allowed by federal and state confidentiality laws and regulations
- File a grievance or complaint about the services you receive without fear of retaliation orreprisal of any sort
- Have family members, friends or others involved in your treatment with your consent and approval
- Receive services that comply with all applicable federal and state laws, rules and regulations
- File a grievance with an outside third party if you feel that the organization has not satisfactorily addressed any concerns you have or, does not adequately address any formal grievance you submit
- To request a transfer to another program if you believe you are not receiving care that is meeting your needs and preferences
- You may also have additional rights afforded to you based on federal, state, and local regulations. Your service coordinator will advise you of any additional rights that you may have.
Program Participant Responsibilities: As a program participant you have the responsibility to:
- Refrain from all forms of physical violence or abuse toward other program participants, staff, or visitors
- Refrain from abusive language, disruptive behavior or overt sexual conduct
- Refrain from loitering outside the organization’s facilities
- Refrain from bringing any type of weapon into the organization’s facilities or property
- Refrain from bringing any illicit (illegal) drug or alcohol onto the organization’s property
- Refrain from using illicit drugs or alcohol while participating in services provided by the organization
- Use tobacco only in designated areas
- Attend all services required by the organization to meet agreed upon goals
- Notify any outside treatment provider (Physician, case worker, counselor, etc.) of participation in services, should your treatment impact, or compromise, the provision of those services
- Treat other program participants, staff, and visitors in a respectable manner.
Patient Print Name
Date

MonthDayYear
Date
Patient Signature (Age 9+)

Clear
Patient/Parent Signature (If applicable)

Clear
Should be Empty:

Patient Information

Consent For Treatment

Consent for Services, Emergency, & Transportation

Family Involvement Consent/Denial

Follow-up Contact Consent

Agreement to Receive Electronic Communication

Program Participant’s Rights and Responsibilities Acknowledgment