This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.
THE THERAPY PROCESS
Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.
Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.
IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand:
• You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
• If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee.
• You must follow all safety protocols established by the practice, including:
• Following the check-in procedure;
• Washing or sanitizing your hands upon entering the practice;
• Adhering to appropriate social distancing measures;
• Wearing a mask, if required;
• Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
• Telling your Provider if you or someone in your home tests positive for COVID-19.
• Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.
TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:
• Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.
• Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
• Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.
CONFIDENTIALITY
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.
RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes/other secure storage service. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.
COMMUNICATION
You decide how to communicate with your Provider outside of your sessions. You have several options:
• Texting/Email
• Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
• Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
• Social Media/Review Websites
• If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
• Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.
FEES AND PAYMENT FOR SERVICES
You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy, and should confirm with your insurance if part or all of these fees may be covered. You should also know about the following:
• No-Show and Late Cancellation Fees
• If you are unable to attend therapy, you must contact your Provider before your session. Otherwise, you may subject to fees outlined in your fee agreement. Insurance does not cover these fees.
• Balance Accrual
• Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
• Administrative Fees
• Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.
• Insurance Benefits
• Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive;
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.
• Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
• Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
• When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider could tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
• Payment Methods
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.
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Adolescent & Adult Informed Consent Form
Privacy of Information Shared in Counseling/Therapy: Your Rights and Our Policies
What to expect:
The purpose of meeting with a counselor or therapist is to help with problems in your life that are bothering you or keep you from being successful in essential areas of your life. You may be here because you want to talk to a counselor, therapist, psychologist, or other mental health professional about these problems. Or, you may be here because your parent, guardian, doctor, teacher, law enforcement, or the courts had concerns about you. When we meet, we will discuss these problems. We will ask questions, listen to you, and suggest a plan for improving these problems. You must feel comfortable talking to me about the issues that are bothering you. Sometimes, these issues will include things you don’t want your parents or guardians to know about for adolescents. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an essential and necessary part of good counseling.
As a general rule, we will keep the information you share in our sessions confidential unless we have your written consent to disclose certain information. However, exceptions to this rule are important for you to understand before you share personal information with us in a therapy session. In some situations, we are required by law or our profession’s guidelines to disclose information whether or not we have your permission. Listed are some of the exceptions.
Confidentiality cannot be maintained when:
Ø You tell us your plan to cause severe harm or death to yourself, and we believe you have the intent and ability to carry out this threat in the very near future. We must take steps to inform a parent or guardian of what you have told us and how serious we believe this threat to be. We must make sure that you are protected from harming yourself, including but not limited to self-harming.
Ø You tell us your plan to cause severe harm or death to someone else who can be identified, and we believe you have the intent and ability to carry out this threat in the very near future. In this situation, we must inform your parent or guardian and inform the person you intend to harm and the appropriate enforcement agency.
Ø You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. We will need to use professional judgment to decide whether a parent or guardian or other appropriate authority should be informed in these situations.
Ø You tell us, or we have reason to believe you are abused physically, sexually, or emotionally or that you have been abused in the past. In this situation, we are required by law to report the abuse to the Illinois Department of Children and Family Services (DCFS). For additional information https://www2.illinois.gov/dcfs/safekids/reporting/Pages/index.aspx
Ø You are involved in a court case, and a request is made for information about your counseling or therapy. If this happens, we will not disclose information without your written consent unless the court requires us to. We will do all we can within the law to protect your confidentiality, and if we are required to disclose information to the court, we will inform you that this is happening.
Communicating with your parent(s) or guardian(s):
Except for situations such as those mentioned above, We will not tell your parent or guardian specific things you share with me in our private therapy sessions. These situations include, but are not limited to, activities and behavior that your parent/guardian would not approve of — or would be upset by — but that do not put you at risk of severe and immediate harm. However, suppose your risk-taking behavior becomes more serious. In that case, I will need to use my professional judgment to decide whether you are in severe and immediate danger of being harmed. If we feel that you are in such danger, we will communicate this information to your parent or guardian.
Example: If you tell us that you have tried alcohol at a few parties, We will keep this information confidential. If you tell us that you are drinking and driving or that you are a passenger in a car with a drunk driver, we will not keep this information confidential from your parent/guardian. If you tell us, or if we believe that based on things you’ve told us, you are addicted to alcohol, we will not keep this information confidential.
Example: If you tell us that you are having protected sex with a boyfriend or girlfriend, we will keep this information confidential. Suppose you tell us that, on several occasions, you have engaged in unprotected sex with people you do not know or in unsafe situations. In that case, we will not keep this information confidential. You can always ask us questions about the types of information we would disclose. You can ask in the form of “hypothetical situations,” in other words: “If someone told you that they were doing ________, would you tell their parents?”
Moreover, we feel your parents/guardians need to know if we believe some confidential or non-confidential information. In that case, we will encourage you to tell your parent/guardian and help you find the best way to tell them. Also, when meeting with your parents, we may sometimes describe problems in general terms, without using specifics, to help them know how to be more helpful.
Communicating with other adults:
School: We will not share any information with your school unless we have permission from your parent or guardian. Sometimes We may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for us to give suggestions to your teacher or counselor at school. In all situations, we will use our professional judgment to decide whether to share any information.
Medical Doctors: Sometimes, your doctor and DBHHC staff may need to work together; for example, if you need to take medication in addition to seeing a counselor or therapist. We will get your parent/guardian’s written permission in advance to share information with your doctor.
In Case of Emergency:
Call 911 in case of emergency – Dabney Behavioral Health does not have a 24/7 emergency response line.
Crisis Hotlines
National Domestic Violence Hotline
https://www.acf.hhs.gov/fysb/ndvh
800-799-7233
National Sexual Assault Hotline
https://www.rainn.org/resources
800-656-4673
National Suicide and Crisis Lifeline
https://afsp.org/988-suicide-and-crisis-lifeline
988 or 911
Department of Children and Family Services
https://www2.illinois.gov/dcfs/Pages/default.aspx
800-252-2873
Cares Line – State of Illinois – 24/7 Days a Year
https://www.dhs.state.il.us/page.aspx?item=123539
800-345-9049
Illinois Warm Line (Mental Health and/or Substance Issues)
https://www.dhs.state.il.us/page.aspx?item=123539
866-359-7953
Contact Rules
Patients who are a “No Call/No Show” without a 24-hour Notice of cancellation via the patient portal or phone call 3 times within any given 6-month period can be discharged and subject to be reassessed by the Intake Team for medical necessity.
Statement of Discharge
Effective September 9, 2022, a Statement of Discharge for all patients discharged by the LPHA or other designated individual will be placed in the patient portal for download. Also, the patient can request a copy be mailed via the US Postal Service.
Civil Rights:
Ø You have the right to be treated with dignity and respect.
Ø You have the right to services without discrimination on the basis of ethnicity, creed, race, religion, age, marital status, financial status, physical or developmental abilities.
Ø You have the right to make decisions about your course of treatment and have treatment conducted in a private space.
Ø You will not be denied, suspended, or terminated from services or have services reduced for exercising any of your rights.
Rights to Treatment:
Ø You have the right to an individualized treatment plan and be informed when there is a change or need to refer to other services.
Ø You have the right to know the names and professional credentials of your staff members.
Ø You have the right to discuss treatment services and change agencies if you feel the treatment is inappropriate to your needs.
Ø You have a right to request a “Clinical Review” when you do not agree with the treatment staff team’s decisions. The assigned Clinical Reviewer will render an independent decision following the receipt of information from all parties.
Ø You have a right to file a grievance if you feel that your treatment has not been appropriate or that your rights have been violated in any manner. This grievance will be initiated at the worker level and may go up to the Executive Director if not resolved before.
Ø You have the right to treatment that is free from abuse, neglect, or exploitation.
Ø You have a right to refuse treatment at any time. You have the right to refuse to participate in audio/videotaped sessions, including Zoom or activities.
Ø You have a right to refuse to participate or to be interviewed for research or publicity purposes.
DBHHC Responsibilities:
Ø Protect your rights in accordance with Chapter Il Of the Mental Health and Developmental Disabilities Code. Protect your confidentiality according to the Confidentiality Act and the Health Insurance Portability and Accountability AQ (HIPAA).
Ø Provide ethical and competent treatment, assign qualified staff to cases, and maintain accurate clinical records.
Ø Protect your rights in accordance with Chapter Il Of the Mental Health and Developmental Disabilities Code.
Ø Provide referral and linkage to Other social service agencies.
Ø Provide an accounting of any disclosures we have made related to your health information upon your request.
Ø Bill or collect for services either directly or through insurance or other third-party payers.
Ø Communicate with courts as mandated by statutes, Rules, or Court decisions (IDMH and IDCFS).
Mutual Responsibilities of DBHHC and Patient/Client:
Ø Develop goals and timeframes for achievement.
Ø Choosing and developing a treatment plan. Identifying and developing appropriate treatment alternatives.
Ø Fulfilling any financial responsibility.
All Rights Protected in accordance with:
Ø Mental Health & Developmental Disabilities Code, Chapter Il, 2002; Health Insurance Portability and Accountability Act, 1996 (HIPAA); Mental Health & Developmental Disabilities Confidentiality Act, 2002
Telehealth:
Ø Dabney Behavioral Health Hospital clinical therapists and staff may communicate with me electronically to provide services via video conference platforms, email, or telephone.
Ø I am aware that there is some level of risk that third parties might be able to read unencrypted emails and other media. I further agree that I am responsible for providing Dabney Behavioral Health Hospital and its agents with any updates to my email and/or mobile phone number or other media access points.
Ø I understand that some therapy sessions may be recorded for training purposes.
INFORMED CONSENT FOR TELEMEDICINE SERVICE
INTRODUCTION
Telemedicine involves using electronic communications to enable healthcare providers at different locations to share individual patient medical information to improve patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up, and/or education and may include any of the following:
Patient medical records
Medical images
Live two-way audio and video
Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption.
EXPECTED BENEFITS
Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
More efficient medical evaluation and management.
Obtaining the expertise of a distant specialist.
POSSIBLE RISKS
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision-making by the physician and consultant(s);
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
In infrequent instances, security protocols could fail, causing a breach of privacy of personal medical information;
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:
I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine that identifies me will be disclosed to researchers or other entities without my consent,
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time without affecting my right to future care or treatment,
I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction and may receive copies of this information for a reasonable fee,
I understand that a variety of alternative methods of medical care may be available to me and that I may choose one or more of these at any time. (name of Physician) has explained the alternatives to my satisfaction,
I understand that telemedicine may involve electronically communicating my personal medical information to other medical practitioners who may be located in other areas, including out of state.
I understand that it is my duty to inform (name of Physician) of electronic interactions regarding my care that I may have with other healthcare providers.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care but that no results can be guaranteed or assured.
I attest that I am located in the State of California or Illinois and will be present in the State of California or Illinois during all telehealth encounters with (Dabney Behavioral Health Clinicians).
PATIENT CONSENT TO THE USE OF TELEMEDICINE
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
I understand a copy of this form will be available for me to print.
I hereby authorize (name of Physician) to use telemedicine in the course of my diagnosis and treatment.
Cost of Services
(All fees are subject to change without notice. A copy of updated fee schedules can be requested from the office staff)
Ø IATP (Individual Assessment Treatment Planning) is billed at $90.00 per 15-minute increment.
(CPT Code: H2000)
Ø Clinical Testing and Assessment is billed $ 90.00 in 15-minute increments. (CPT Code: H2000)
Ø Individual Therapy is billed at $55.00 per 15-minute increment. (CPT Code: H0004)
Ø Family Therapy is billed at $55.00 per 15-minute increment. (CPT Code: H0004)
Ø Crisis Intervention is billed at $95.00 per 15-minute increment. (CPT Code: H2011)
Ø Documentation Fee (i.e., documents for workers' compensation, educational or clinical collaboration) $137.76 per document request.
Private Pay (Individuals without healthcare insurance or with policies not Accepted by DBHHC):
Ø $360 for IATP intake mental health assessment and evaluation per session, in addition to Clinical Testing and Assessment, is billed at $ 90.00 in a 15-minute increment.
Ø $220 per session plus $55.00 in 15-minute increments after the first hour.
All fees and/or insurance Co-pays are due at the time of service unless Dabney Behavioral Health Hospital has approved prior arrangements. If a client’s account is more than 30 days past due, DBHHC reserves the right to proceed with collection actions and to hold the client liable for collect fees, including but not limited to attorney and court costs.
Credit Card Convenience Fee
Effective February 2022, the DBHHC will be changing a convenience fee of (3.75%) or a minimum of $2.00 for each credit card transaction processed. No transaction fee will be assessed on cash, check, or electronic payments made at our location(s).
Electronic Signature:
The ESIGN Act is a federal law passed in 2000. It grants legal recognition to electronic signatures and records if all parties to a contract choose to use electronic documents and sign them electronically. Dabney Behavioral Health Hospital permits patients/clients to sign their documents electronically by providing identification and verbal consent to a Dabney Behavioral Health Hospital representative.
Minor/Dependent Information
Adolescent’s privacy:
I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress and/or may be asked to participate in therapy sessions as needed. I understand that I will be informed about situations that could endanger my child. In these circumstances, I know this decision to breach confidentiality is up to the therapist’s professional judgment and may sometimes be made in a confidential consultation with their consultant/supervisor.
Authorization Form to Provide Services
Consent for Services/Treatments: I consent to the treatment provided by Dabney Behavioral Health Hospital and its affiliates/agents, employees, contractors, or designees. I authorize the mental and physical health services deemed necessary or advisable by caregivers to address my needs or my child’s needs.
Authorization for Release of Personal Health Information: I authorize Dabney Behavioral Health Hospital and its affiliates/agents, employees, contractors, or designees to disclose my personal health information for the purpose of diagnosing or providing my treatment, obtaining payment for my care, or for the purposes of conducting the healthcare operations of the Service Provider. I authorize the Service Provider to release any information required in the process of applications for financial coverage for services rendered. This authorization allows the provider to release clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent/agency.
Assignment of Insurance Benefits/Payment Guarantee/Collection Fees: I authorize payment to be made direct to the Service Provider for any covered or non-covered services, as defined by my insurer. I understand that if my account balance becomes overdue and the overdue account is referred to a collection agency, I will be responsible for the cost of collection, including a reasonable attorney fee.
Complete if No Insurance, HMO, or Private Insurance coverage: Receiving DHS Funding – The Department of Human Services may pay for some or all of the cost for your mental health services.
I authorize the Service Provider to bill the DHS for my services. I understand the provider will report demographic, household income, and mental health services information to the Illinois Department of Human Services.
I Do Not authorize the Service Provider to bill DHS for my services, and I understand the provider will not report demographic, household income, and mental health service information to the Illinois Department of Human Services. ( ) Initial and Date:__________________________________________________
Privacy Policy: I acknowledge having received a copy of this document. I understand my rights include the right to see and copy my record, to limit disclosure of my health information, and to request an amendment to my record. I understand that I may revoke my consent to release my healthcare information in writing, except to the extent the Service Provider has already made disclosures with my prior consent.
Inactive Client/Patient Treatment plans
Please note that all patient “Treatment Plans” must be updated every 6 months, and failure to schedule and complete a re-assessment will result in the patient being discharged from DBHHC. If discharged and the former patient wants to seek additional mental health services, they can request a new patient intake.
Moreover, DBHHC does provide clinical training for graduate degree students seeking to complete their internship, practicum, and clinical licensure hours required to complete their educational or professional degree program and/or licensure.
Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as you progress with therapy, you can ask your therapist or the agency’s administration at any time.
Acknowledgment
My signature on this document represents that I have received the Consent for Services form and that I understand and agree to the information therein. Further, I consent to use an electronic signature to acknowledge this agreement.