I voluntarily agree to undergo mental health treatment and understand that I may end treatment at any time. I understand that my therapist or counselor cannot guarantee results (e.g., less depressed, improved marital satisfaction, etc.) of mental health services. However, there will be clearly stated reasons, goals, and objectives for continuing/discontinuing mental health treatment. This will be discussed with my mental health provider. I understand that there may be some risks in participating in mental health services. These may include, but are not limited to, addressing painful emotional experiences and/or feelings; being challenged or confronted on a particular issue; re-uniting with family members; or being inconvenienced due to costs/fees of counseling.
I am aware that I can discuss any unforeseen risks versus benefits with my mental health provider at any time. Furthermore, I understand that this “Consent to Treatment and Privacy Practices form” is not intended to be “all inclusive” of aspects of my mental health treatment. It is only intended to provide some useful information before deciding to engage in mental health treatment.
Momentum Counseling is committed to the protection of your mental health information as required by federal and state law. Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:
DUTY TO WARN AND PROTECT
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.
ABUSE OF CHILDREN AND VULNERABLE ADULTS
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.
PRENATAL EXPOSURE TO CONTROLLED SUBSTANCES
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
MINORS/GUARDIANSHIP
Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
INSURANCE PROVIDERS (when applicable)
Insurance companies and other third party payers are given information that they request regarding services to clients.