Alpha & Omega Therapy and Doula Services Inc., Mental Health Intake, Part 2

For the Following Information (specific information requested):  Client's behavioral reports/recommendations. 

For the Following Purpose (specific need/reason):  Collaboration

 

Treatment services are not contingent upon, or influenced by, the client's decision to or not to permit the release of this information.  The client's consent shall be freely and voluntarily given.  

The information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but not limited to, diseases such as hepatitis, syphilis, gonorrhea, and AIDS.  

Psychiatric Records: Oklahoma State Law (76 OS 1986, Section 19) provides that the psychological or psychiatric records may be provided to a patient only if the treating physician/practitioner consen to release or upon a request of a court order, issued by a court of competent jurisdiction.  Therefore, the agency wil not release psychological or psychiatric records to patients, their guardians or agents (including attorneys) except with the consent of the treating physician/practitioner or upon the receipt of a court order, issued by a court of competent jurisdiction.  

Drug/Alcohol Records:  Confindentiality of drug/alcohol abuse records is protected by Federal Law.  Federal Regulations (42 CFR Part 2) prohibit you from making further discolsure of this information unless disclosure is expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42CFE Part 2.  A general authorization for the release of medical or other information is not sufficient for this purpose.  The Federal rules restrict the use of the information to riminally investigate for prosecute any alcohol/drug patient.  

I understand that my records are protected under the Federal and State Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations.  I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g. probation, parole, etc.) 

I do not authorize further release to any other party.  I do understand that the agency and its staff, employees, officers, and directors cannot be responsible for the confidentiality disclosed after said information has been released pursuant to this authorization, and hereby, release them from any liabilty arising from such disclosure.  I authorize this consent to release confidential information.  

For the Following Information (specific information requested):  Information needed or the named person to receive services

For the Following Purpose (specific need/reason):  Collaboration

Treatment services are not contingent upon, or influenced by, the client's decision to or not to permit the release of this information.  The client's consent shall be freely and voluntarily given.  

The information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but not limited to, diseases such as hepatitis, syphilis, gonorrhea, and AIDS.  

Psychiatric Records: Oklahoma State Law (76 OS 1986, Section 19) provides that the psychological or psychiatric records may be provided to a patient only if the treating physician/practitioner consen to release or upon a request of a court order, issued by a court of competent jurisdiction.  Therefore, the agency wil not release psychological or psychiatric records to patients, their guardians or agents (including attorneys) except with the consent of the treating physician/practitioner or upon the receipt of a court order, issued by a court of competent jurisdiction.  

Drug/Alcohol Records:  Confindentiality of drug/alcohol abuse records is protected by Federal Law.  Federal Regulations (42 CFR Part 2) prohibit you from making further discolsure of this information unless disclosure is expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42CFE Part 2.  A general authorization for the release of medical or other information is not sufficient for this purpose.  The Federal rules restrict the use of the information to riminally investigate for prosecute any alcohol/drug patient.  

I understand that my records are protected under the Federal and State Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations.  I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g. probation, parole, etc.) 

I do not authorize further release to any other party.  I do understand that the agency and its staff, employees, officers, and directors cannot be responsible for the confidentiality disclosed after said information has been released pursuant to this authorization, and hereby, release them from any liabilty arising from such disclosure.  I authorize this consent to release confidential information.  

Each person being served by a licensed mental health provider or organization has the right to name a Treatment Advocate for the following reasons:  1.  Someone with whom you would like to partner with during your course of treatment and, 2.  Someone you trust and whose advice you value, such as a family member, spouse/partner, friend or representative from an advocacy organization.  You have the right to set limits regarding the level of involvement of the person you select and you have the right to change your selection at any time.  You also have the right to not name a Treatment Advocate.  Should you name a Treatment Advocate, this person must agree to sereve and adhere with all standards of confidentiality.  

File Original in client chart

1 copy will be given to the client

1 copy will be given to Treatment Advocate