INFORMED CONSENT FOR TREATMENT

120 East Trinity Place Ÿ Decatur, GA 30030

Phone (404) 378-2300 Ÿ Fax (404) 378-2394

CLIENT INFORMATION (Confirm correct name spelling and DOB with client and/or guardian

This document contains important information about Pathways Transition Programs, Inc. (PTP) services and business policies. Please read it carefully and ask questions for clarification if needed. When you sign this document, it will represent an agreement between you and PTP and authorize our staff to begin your counseling services.

PTP is a private behavioral health agency serving children, teens, adults, and families in 40+ north central Georgia Counties. All of our therapists are either Licensed Professional Counselors (LPC), Licensed Clinical Social Workers (LCSW), Associate Professional Counselors (LAPC), or Licensed Master Social Worker (LMSW) under clinical supervision and direction. We employ additional staff as Paraprofessionals with college degrees in various fields in support roles. All clinical staff participate in peer consultation as well as ongoing continuing education.

We approach our work using a comprehensive, integrated model for understanding and working with clients from all walks of life developed by Dr. Sunaina Rao Jain, our founder, called The Kaleidoscope Model of Therapy™. All work with our clients is based on the fundamental premise that our behavior patterns reflect our understanding of ourselves and the world we live in, and change is basically about shifting this perspective enough to risk trying new ways of coping and thriving.

The techniques we use to help clients heal and learn come from a variety of sources since each person’s needs are different; there is no one-size-fits-all approach. However, the choice of methods comes from our understanding, in collaboration with our clients, of what they need most to regain control over the direction of their lives.

vServices provided at PTP include, but are not limited to, counseling and psychotherapy; psychiatry and medication management; intensive family-based therapy (IFI); behavioral aid; school-based support; group counseling; diagnostic and assessment reviews; state-funded wraparound services, early intervention, prevention of unnecessary placement, and family assessments. vYou will receive a comprehensive assessment and a treatment plan. You will be involved in the creation of treatment goals. These plans will be updated as needed with you.

While receiving PTP services, your rights are protected by the Georgia Department of Human Resources.

You have the right to vCare suited to your needs. vServices that respect your dignity and protect your health and safety. vBe informed of the benefits and risks of your service plan. vParticipate in planning your own program. vRefuse service, unless a clinician thinks that refusal would be unsafe for you or others. vPrompt and confidential services, even if it is determined you are unable to pay. vReview your records with your clinician, unless he or she thinks it is not in your best interest. vExercise all civil, political, personal and property rights to which you are entitled as a citizen. vRemain free of physical restraints or time-out procedures, unless such measures are required for providing effective treatment or protecting the safety of yourself or others. vBe free of physical, sexual or verbal abuse. vReceive services without discrimination on the basis of your political affiliation, religion, race, color, gender, sexual orientation, mental or physical handicap, nationality, or age.

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You also have the right to vConsult with your clinician about any concerns related to your treatment to ensure your wellbeing. vAsk questions about any procedures or techniques used by your clinician. vLearn about alternative methods of care. vConfidential communications between yourself and PTP. vReview your medical record. vRequest and receive copies of your medical record and to request your record be amended. v Review PTP Business Associate Agreements for entities with access to your medical record in our office. vRequest an accounting of all disclosures made by PTP of your private health information in the six years or less prior to the date requested. vEnd treatment with PTP at any time. vFile a complaint if you believe any of your rights have been restricted or denied.

Per the Georgia Department of Human Resources, it is your responsibility to vBe honest with the staff providing services. vCooperate in implementing and following your service plan. vKeep all appointments on time and give 24 hours of notice if cancellation is necessary. vRespect the rights and confidentiality of other clients. vMake timely payment of PTP fees or arrangements for payment by another party.

vYour clinician may end services at any time for any one of the following reasons: Failure to attend scheduled individual or family sessions. Concerns for safety and well-being of the children in the home. Implied or explicit aggressive behaviors or threats toward other clients or our staff. (see Aggressive Behavior below)

vRecordings are not permitted. You agree not to record any conversations with your provider before, during, or after any consultation with any recording device, e.g., phone, tape, recorder, video, smartwatch, etc., without your provider’s consent. Your provider will not record you without your consent. You understand that violating this provision may lead to legal action. In the event PTP must take legal action, you agree to indemnify the provider and PTP against all legal costs, including, but not limited to, attorney's fees and court costs.

vFull payment is expected at the time services are rendered at PTP, for all services received by PTP, unless claims are filed to your insurance company or another payor. Refusal to pay fee may result in termination of services. vWe require 24 hours of notice for appointment cancellations. Appointments canceled without 24 hours of notice will be subject to cancelation fee. vFor accounts past due more than 30 days, interest will be added (2% per month).

Information related to my insurance and/or payor is true and correct to the best of my knowledge and will

remain confidential. I am responsible for payment at the time services are rendered unless filed to insurance

or payor on my behalf. If my insurance provider indicates that a co-payment is due, I am responsible for the

co-payment at the time services are rendered.

I authorize the release of medical information necessary to process insurance claims for services rendered by

I authorize payment of medical benefits to PTP for services; claims may be filed on my behalf.

I authorize correspondence with primary physician, as needed for insurance approval/authorization of mental

vMost clients exit therapy feeling better able to care for themselves and their loved ones. However, there are no guarantees that any therapy treatments offered anywhere will be successful; no one at PTP can offer a guarantee regarding the outcome of your treatment.

vUnderstanding one’s self more thoroughly: defining personal strengths, identifying triggers that interfere with normal life functioning, and finding opportunities for personal development. vOvercoming bad habits and developing healthy coping skills for managing difficult circumstances. Improved relationships with family, friends, and others. vEnhanced resilience. vIdentify paths towards achievement of goals.

vSecure, private communications cannot be fully assured using mobile phones and email. Please indicate which communications you allow us to use and under what circumstances. You may alter your preferences at any time.

vWhen you use a mobile phone or email to contact us, we will consider this your implied consent allowing us to reply using the same non-secure methods pending clarification from you. vIf yl only contact you via landline phone, fax, or USPS mail. ou don’t make any selections above, we wil

We are committed to your support and care. We want to respond to you in a timely manner; we return calls within 24 hours Monday through Thursday. Calls received on Friday, Saturday, or Sunday are returned on Monday.

If you have an emergency, call 911. For non-emergency calls

vWeekdays Monday through Friday, between 9am-5pm, please call your clinician’s mobile phone. You may also call our main office at (404)378-2300 to speak to the front office or press zero (0) to leave a voicemail message. Make sure to state your name

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clearly, your clinician’s name, and your call back phone number. vAfterhours, weekends, and holidays After business hours, on weekends, or during holidays, please leave a message on your clinician’s mobile phone, or call our main office at (404) 378-2300. Press zero (0) to leave voicemail for the front office. If your call is urgent (but not an emergency), please call dial (404) 378-2300 and press two (2) to speak with our afterhours attendant.

Our regulatory agencies require us to inform you that PTP does not support nor condone the use of corporal punishment at any time.

As stipulated by Georgia state law, all PTP staff are mandated reporters of child abuse or neglect. Mandated reporters are required to submit a report to the appropriate DFCS county office if they believe a minor child has experienced any of the following from a parent or guardian: vNon-accidental physical injury. vNeglect or exploitation. vSexual assault or sexual exploitation.

Just as you deserve to be free of physical, sexual, and verbal abuse while seeking treatment at PTP, our staff also have the right to be free of physical, sexual, and verbal abuse while working with you. vAny threat, implied or explicit, about inflicting violence, sexual abuse, or harassment on another individual will be taken seriously. vPhysical confrontations will be stopped immediately using the safest means possible. Staff will not use restraints or seclusion to stop aggressive behavior, but emergency holds may be used to stop aggressive behavior. vIf necessary, law enforcement will be contacted to come to our office to document an altercation, take statements, and make arrests if necessary. vIf an injury is sustained requiring medical attention, we will arrange transportation to the nearest hospital. PTP staff will accompany you. vAn incident report will be completed by your clinician and submitted to our clinical director. The clinical director will meet with your Treatment Team and the Continuous Quality Improvement (CQI) Committee within five working days of the incident. vAll involved parties will meet with the clinical supervisor within five days of the incident. If anyone on your Treatment Team feels unsafe, you will be discharged from our service. vYour referrer may be notified.

The staff at PTP want to know that you are satisfied with our services. We also understand that with any ongoing relationship there may be times of conflict. It is important for your complaints or concerns are heard. There are various options available to you for submitting a complaint. vIf you feel uncomfortable bringing concerns to your clinician, or if feel a situation has not been resolved with your clinician to your satisfaction, please contact our clinical director at (404) 378-2300 x5011. You can expect a response within five business days. The clinical director will schedule a meeting with you and all concerned parties at a PTP office. PTP will provide transportation if needed to ensure there are no barriers for your attendance this staffing. vYou can complete an anonymous online feedback survey that can be found on the footer of any webpage on the PTP website. vIf you do not feel the situation is resolved to your satisfaction at PTP, you may contact those entities responsible for PTP funding (claim payments) and monitoring. This includes your local DFCS and DJJ offices. Or, if you do not receive satisfaction from these agencies within 30 days of your submitted complaint, you can you can contact the Georgia Department of Behavioral Health at (404) 657-5964. You may also contact HFR Complaint Intake: Toll Free (800) 878-6442 Fax: (404) 657-8935, https://dch.georgia.gov/divisionsoffices/hfrd/facility-licensure/hfrd-file-complaint, or by mail to: 2 Martin Luther King Jr Dr SE, East Tower, 17th Floor, Atlanta GA 30334. vIn the event you need to reach DJJ, you are welcome to contact their Office of Ombudsman in the following ways:

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a.Email: djjombudsman@djj.state.ga.us b.Mail: Department of Juvenile Justice, Office of Ombudsman, 3408 Covington Highway, Decatur, Georgia 30032 c.Phone (toll-free): 1-855-396-2978 d.Online: complaint referral form is located at http://www.djj.state.ga.us/Employees/DJJDrupalOmbudsmanForm.aspx e.Calls or visits may be made to the local facility or Community Services Office

I am an adult, over 18 years of age; I am the client

The client is a minor; I am the client’s parent

The client is a minor; I am the client’s legal guardian

INTAKE2-ENG–INFORMED CONSENT Revised 4/17/2025