I, hereby consent to receive mental health services from Second Chance Counseling & Wellness, LLC (hereinafter referred to as "SCCW") and its staff.
1. Authorization for Services:
I authorize SCCW and its staff to provide mental health services, including but not limited to:
Assessment/Re-Assessment
Skills Building & Training
Outpatient Therapy
[ and other services offered, e.g., Group Therapy, Couples/Family Therapy, Medication Management, Case Management, etc. ]
2. Collection and Use of Information:
I authorize the collection of necessary administrative and clinical data regarding me. I understand that such data will be computerized for statistical, programming, and billing purposes. I understand that information regarding me will be collected responsibly and maintained in a confidential clinical record.
3. Confidentiality and Disclosure:
I understand that my records and information shall remain confidential except in the following instances:
Information required by third-party payers and parties I authorize the Facility to release information to shall be forwarded to them.
Records shall be open to Facility staff as needed and to appropriate state mental health officials.
Information may be exchanged if I sign a written release form indicating the nature of the information to be released.
Information that indicates a severe threat to the life or safety of another person or to myself shall be forwarded to the threatened parties or appropriate agencies to the extent necessary to protect life and safety.
Information will be released if required under a court subpoena.
Suspected abuse or neglect shall be reported to Protective Services as mandated by law.
State and Federal law prohibits the disclosure of any information identifying me as receiving alcohol/drug services unless I consent in writing, the disclosure is allowed by court order, disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluations.
Federal Law does not protect any information about a crime committed by me either at the Facility or against any person who works for SCCW or about any threat to commit such a crime.
SCCW may share information with my consent with other associated facilities, such as group homes, Departments of Social Services, Court Services, and Area Programs if I am seen in two or more of these agencies.
4. Non-Discrimination:
I understand that all services will be provided regardless of gender, race, color, national origin, sexual orientation, religious preference, or disability.
5. Emergency Care:
In the event of a medical or psychiatric emergency, I give permission for staff to seek emergency care on my behalf.
6. Financial Responsibility:
I agree to satisfy my financial obligation. I understand payment is due at the time services are rendered unless payment arrangements are made.
7. Right to Refuse Treatment:
I have the right to accept or refuse any medication, procedure, test, or treatment. Exceptions to this right include emergencies, court orders, or if I am under 18 years old and my parent or guardian has given permission.
8. Consent to Treatment:
I hereby consent to the treatment described above. I acknowledge that I have had the opportunity to discuss the nature and purpose of these services, the risks and benefits of treatment, and the limits of confidentiality with staff. I understand that I may withdraw this consent at any time, except as otherwise provided by law, by providing written notice to SCCW.
9. Medication (if applicable):
I understand that medication may be a part of my treatment plan. I consent to taking medication as prescribed and to following the instructions provided by my prescribing physician. I understand the importance of discussing any side effects with my doctor.
10. Electronic Communication:
I consent to communicating with Second Chance Counseling & Wellness via email and/or text message for scheduling purposes and other non-clinical matters. I understand the potential risks to privacy associated with electronic communication.