INFORMED CONSENT

INFORMED CONSENT FOR RECEIVING

LIFEWISE STL SERVICES
As a participant of LifeWise StL, you have certain rights and responsibilities when participating in our programs, services, and events.

YOU HAVE THE RIGHT:

1. TO RECEIVE SERVICES WITHOUT DISCRIMINATION based on race, ethnicity, religion, gender, sexual orientation, creed, age, marital status, or disability.

2. TO BE INFORMED ABOUT THE TERMS under which services will be provided. We will collaborate with you to determine the appropriate services for your needs. You have the right to a clear explanation of any service available to you, including potential risks.

3. TO CONSIDERATE AND HUMANE SERVICES with dignity, respect, and professionalism in an environment free from verbal and physical abuse.

4. TO VOICE CONCERNS OR COMPLAINTS to the CEO/President at

314-627-1223 without fear of discrimination or reprisal. Every attempt will be made to resolve the matter so that services may continue unhindered.

5. TO REFUSE SERVICES OR TO DISCONTINUE SERVICES AT ANY TIME AND FOR ANY REASON. If the participant is a minor, the parent(s) or legal guardian has the right to refuse or stop services on behalf of the minor. Your Provider also has the right to refuse or terminate services, in which case you will be provided with alternative service options.

6. TO CONFIDENTIALITY. Personal information shared by you during your participation in LifeWise StL programs, services, and events will remain confidential and will not be disclosed to external agencies or persons without your written permission, except as required or permitted by law. Any use of LifeWise StL mental health services is considered Protected Health Information (PHI) and is further protected according to HIPAA regulations.
LIMITS TO CONFIDENTIALITY:

Certain limits and exceptions to participant confidentiality include:
- Medical emergencies, including harm to self or others
- Cases of child or elder abuse
- Court order
- Supervision/Consultation
- Reporting to funders
ADDITIONAL NOTICES:
- RIGHT TO APPEAL: You have the right to appeal decisions made regarding your services in accordance with state regulations.
- REFERRAL TO SERVICES: If LifeWise STL cannot meet your needs, we will assist you in finding alternative services.
BY SIGNING THIS FORM, I CERTIFY THAT:
- I have read and understood my rights and responsibilities as outlined above.
- I understand that while I can expect to benefit from services, this is not a guarantee.
- I consent to receiving services provided by LifeWise StL under the terms detailed above.
Full Name of LifeWise Participant
Participant Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Which of the following best describes the signer?
SIGNATURE
Parent/Guardian Full Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
----- Please do NOT fill out anything below this line -----

By typing your name below, you - as a LifeWise StL staff person or authorized representative - attest that you have explained the form in full to the participant or their parent/guardian and answered all questions.
Staff Name
First & Last Name
Upload Signed Copy if Completed on Paper

Staff are still required to fill out all fields above to reflect attachment
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