I understand that I will be informed of any changes in the service/treatment service, program, and/or staff assignments. I have the right to agree or disagree to any referrals for this service or any other that may arise in the future prior to the above named individual being placed in any service or program, except in emergency situations.
I understand that there are alleged benefits, potential risks, and possible alternative methods of treatment and I may discuss these with agency staff at any time before, during, and after treatment.
In the case of accident or illness while the above named individual is receiving service/treatment from PHILA Health Systems of NC, I give my consent for the staff to provide and/or obtain emergency medical treatment.
I authorize PHILA Health Systems of NC staff to provide transportation as deemed necessary.
I fully understand the statements above. This form has been read an explained to me. I may make any concern and/or complaint that I may have regarding treatment by writing to the following address:
PHILA Health Systems of NC
Attn: Clinical Supervisor
11 Union St S. suite 208
Concord, NC 28025
I may also request a meeting to discuss my concerns and/or complaints by writing the Clinical Supervisor at the address above. I understand that the Clinical Supervisor will convene a meeting to hear my concerns and/or complaints and settle any issues that may need resolution.