Informed Consent Form--MH

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Client's Name* This field is required.

First Name

Last Name

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Client's Date of Birth* This field is required.

Date

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Are you currently enrolled for counseling or community support at another facility?* This field is required.

Yes

No

Yes; I will contact current provider for discharge there

Yes, but dual enrollment is allowed by my insurance

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Permission for Dirigo to communicate with you; check all that apply* This field is required.

NO RESTRICTIONS (we may use your phone, email, text messaging, US mail, fax, voice mail,), OR

not by Email

not by Fax

not by Text messaging

not by US Mail

do not leave voice mail

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MY SIGNATURE BELOW FURTHER CONFIRMS THAT:

1. EXPLANATION OF CLIENT’S RIGHTS: I have reviewed and offered a copy of

(a) my rights concerning privacy and confidentiality and access to/use of the clinical record;

(b) the “Clients Bill of Rights”, available at https://www.dirigocounseling.com/wp-content/uploads/Summary-of-Your-Rights.pdf

(c) offered a copy of the “Rights of Recipients of Mental Health Service” booklet, and

(d) been given a chance to ask questions and/or discuss these documents.

2. CONSENT TO ASSESSMENT AND/OR TREATMENT: I have

(a) been informed of the risks and the benefits of participating in this assessment and/or treatment,

(b) I have been given the Provider’s “Professional Disclosure Statement” (where applicable), and

(c) I have the capacity to understand all of the documents before me; and

(d) have the legal authority to sign this Informed Consent.

4. PROOF OF CLAIMS: I allow Dirigo to provide my insurance with the information necessary to establish proof of claims on my behalf for services provided by DCC.

5. FEES: Unless we agree to bill your insurance provider, I agree to pay the fee-for-service (cost of services) which are published on our website at: https://www.dirigocounseling.com/wp-content/uploads/2022/07/Insurance-Fees-Payments-2-_4_.pdf

6. ATTENDANCE POLICY AGREEMENT

I agree to keep my scheduled appointments and arrive on time. I will call at least 24 business hours in advance if I need to change or cancel an appointment. I understand that if I fail to keep my appointments, I may no longer be allowed to schedule appointments in advance. I understand missed appointments can result in discharge from the program.

DCC looks at the number of appointments a client keeps and calculates an Attendance Score. This Attendance Score is the percentage of sessions that were kept after making the appointments. Clients must keep 70% of appointments (for an Attendance Score of 70) or they will lose the privilege of making appointments in advance. We will continue to see you of course but you would only be given same-day appointments when there are openings for you . When attendance improves, then you may once again make appointments in advance.

Please note , Two "no shows" (a “no show” can be defined as missing a scheduled appointment without advanced notification) in a 30-day has the following risks for you as a client:

1. being removed from your recurring appointment time.

2. Being placed on “same day appointments” (you will need to call the morning that you want to see your Provider to see what opening are available for you that day

3. Being placed on the waiting list if you wish to return.

BEST TO SPEAK WITH YOUR PROVIDER IF YOU ARE HAVING BARRIERS TO YOUR ATTENDANCE.

If we are unable to contact you to discuss obstacles, we will proceed with discharge and you will be notified by mail.

7. CONSENT FOR TELEHEALTH COUNSELING (if applicable)

a. While online counseling (AKA “telehealth”) is one means of doing therapy, you may have a different experience if engaged in face-to-face therapy, for which one or more referrals will be made if preferred. Therapy or counseling delivered online may or may not be covered by insurance.

b. Telehealth service is voluntary and the same service is available in a face-to-face setting. You can stop the telehealth visit at any time and request face-to-face. For Mainecare members, your insurance will pay for transportation to a distant appointment if needed.

c. The same privacy and confidentiality rules (spelled out in HIPAA) still apply to our work by telehealth in the same way that it applies to face-to-face (See Informed Consent Part B that all clients sign before services are started at this agency).

d. You shall have the right to be informed of the parties who will be present at the Receiving (Provider) Site and the Originating (Member) Site during the Telehealth Service and shall have the right to exclude anyone from either site.

e. While using every reasonable means to protect and encrypt conversations and records of treatment, when doing therapy by Internet or other electronic means, such encryption cannot be guaranteed. The highest degree of security is being taken utilizing the application which will be a system to provide secure online counseling.

f. You are encouraged to protect your own confidentiality by controlling access to communications with me-such as by using passwords only known by you, controlling access to your computer, deleting data as agreed, etc.

g. It is understood that when communicating by Internet or other electronic means, disruptions in service or other technical difficulties will likely occur from time to time. Should a disruption occur at a time of crisis, I will immediately call you. If you cannot be reached, I may be compelled to contact 911 or law enforcement. In a non-crisis situation, reconnection will commence when able.

8. DIRIGO COUNSELING CLINIC’S GRIEVANCE AND COMPLAINT PROCEDURE:

Any person may bring their complaints in writing or in-person to:

1. the offending person who will document the matter along with any resolutions and other options that were discussed and evaluated AND/OR

2. the offending person’s supervisor and that chain of command up to and including the Clinical Director AND/OR

3. The Division of Licensing and Certification by:

a. phone at: 1-800-383-2441, OR

b. use of the Online Complaint form at https://www.maine.gov/dhhs/dlc/safety-reporting/file-a-complaint>, OR

c. fax at (207) 287-9307, OR

d. mail at: Division of Licensing and Certification; ; 11 State House Station; 41 Anthony Avenue; Augusta Maine 04333, OR

e. email at: DLRS.info@maine.gov AND/OR

4. The offending person’s professional licensing board; contact information may be found at: https://www.maine.gov/pfr/home

9. CONSENT FOR USE OF AI IN CLINICAL DOCUMENTATION:

My Provider may use an AI program called Autonotes.ai which converts my handwritten notes into clear clinical language. This program streamlines the workflow and assists in writing efficient, accurate, and secure documentation. Autonotes ensures that all documentation complies with HIPAA regulations and otherwise protects client information.

10. Minors 12 years old or younger must have a responsible adult on the premises during the counseling session.

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GUARDIANSHIP QUESTIONNAIRE; Unless this form is filled out, it may be assumed that the client is their own guardian. Otherwise, the guardianship of this client is, to the best of my knowledge, as follows:* This field is required.(Select all that apply)

I am the sole guardian for the client.

I share guardianship with another person and that person agrees for me to present the client to Dirigo Counseling Clinic for treatment and will be offering their signed consent for treatment.

I share guardianship with another person but the court has awarded me full medical authority forthis client.

I share guardianship with another person but that person is unreachable; I will be endeavoring to secure their signed consent for treatment.

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I am not the guardian but have the authority to give consent to treatment by reason of: [e.g. DHHS designation; foster parent, etc]

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I am a minor but I give my own consent to treatment because [check all that apply; see 22 M.R.S.A. §1503; 34-A M.R.S.A. §3031(2)]:

I have been living separately from my parents or legal guardians for at least 60 days, and am independent of parental/guardian support for my basic needs.

I am or have been legally married (attach copy of marriage certificate).

I am or have been a member of the U.S. Armed Forces

I have been emancipated by court order

I am residing in a correctional facility pursuant to a conviction as an adult

I am clinically competent with decisional capacity to give my own informed consent for treatment.

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Signature (use mouse or finger)* This field is required.

Clear

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Date* This field is required.

Date

Hour

Minutes

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The above signature belongs to:* This field is required.

The client

A legal guardian

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Guardian Name

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