CONSENT FOR TREATMENT
Risks and Benefits of Mental Health Treatment

Before giving your consent for mental health services, it is important that you are informed of possible risks and benefits of treatment. Mental health services provide you with an opportunity to work with someone who is passionate about working with you to improve whatever set of circumstances caused you to seek services. 

Typical benefits from mental health services include: an improved ability to relate with others; a clearer understanding of self, values and goals; increased academic productivity; an increase in the ability to deal with everyday stress. Taking personal responsibility for working with these issues may lead to greater growth. While no one can guarantee or promise a specific outcome, there are a number of positive outcomes that can result from both short-term and long-term mental health treatment.

Like any healthcare service, there are also potential risks associated with receiving mental health services. Remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings such as anger, sadness, worry, or fear; experiencing anxiety, depression, insomnia, etc. Mental health treatment may challenge some of your assumptions or perceptions, or pose different ways of looking at or thinking about or handling situations. Any of these changes can cause you to feel upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that lead you to seek mental heath services in the first place may result in changes that were not originally intended. Therefore, it is most likely that you may feel worse before you feel better. This is temporary, and a normal part of the process towards personal growth and change. 

Emergencies
If you experience a mental health emergency during business hours please call your clinician directly. Some emergency circumstances may occur when your clinician is unavailable and therefore unable to respond. On these occasions, please contact our office at (2166-326-2472).

Outside of these hours, please call 911 or go to your nearest emergency room. You may also call Mobile Crisis located in your county using the following contact information:

Summit Lake County Cuyahoga County Mobile CrisisAdults: (216)623-6888Crisis HotlineCenter Crisis(330)747-2696 Portage Path (440)953-8255Hotline Support Hotline(800)888-6161 (330)434-9144

Mahoning County Crisis Hotline

Hospital Emergency Line (330)543-7472

I hereby give my consent for Whole Mind Wellness Initiative and its respective clinicians to provide mental/behavioral health services to me and/or my child. I have been given the opportunity to ask any questions regarding services offered and have received satisfactory answers to my questions. I have been informed of the scope and purpose of the services, as well as the risks and benefits, and understand that I may withdraw my consent at any time. I understand I may also refuse any services offered at any time.

FINANCIAL RELEASE

I understand that Whole Mind Wellness Initiative and its respective clinicians may use confidential information about me to bill and be paid for provided services. I have been given the opportunity to ask any questions regarding services offered and have received satisfactory answers to my questions. I hereby consent Whole Mind Wellness Initiative and its respective clinicians to release confidential information to the billing agent, Enduring the Course, Inc. and its contracted clearinghouse, and/or to the funding source(s), and for the funding source to release confidential information to Whole Mind Wellness Initiative and its respective clinicians and Enduring the Course, Inc. for this purpose.

I hereby grant permission for Whole Mind Wellness Initiative and its respective clinicians to provide transportation to myself and/or my child, and agree to hold Whole Mind Wellness Initiative and its respective clinicians harmless for any accident/injury that results from the provision of transportation.

If my child does not meet the height and weight requirements of the State of Ohio to ride without a child restraint system, I am aware that I must provide such a system for transport and failure to do so will result in no transportation for my child.

I hereby give consent for Whole Mind Wellness Initiative and its respective clinicians to seek and sign consent for emergency medical care for myself and/or my child in the event that I am unable to do so for myself or for my child. It is understood that Whole Mind Wellness Initiative and its respective clinicians will attempt to locate me, or another legally responsible adult, as quickly as possible in the event of an emergency situation.

CLIENT RIGHTS/GRIEVANCE POLICIES

I have received and had explained to me the Client Rights and Grievance Policies handout. I have been given the opportunity to ask any questions regarding services offered and have received satisfactory answers to my questions. Whole Mind Wellness Initiative and its respective clinicians provided me with this handout and verbally explained the rights that myself and/or my child has as a client at Whole Mind Wellness Initiative.

Whole Mind Wellness Initiative and its respective clinicians have provided me with the Privacy Rights handout and verbally explained my rights/the rights of my child as a client at Whole Mind Wellness Initiative. I have been given the opportunity to ask any questions regarding services offered and have received satisfactory answers to my questions. I understand these rights are designed to protect my privacy and that no information will be released by Whole Mind Wellness Initiative or its respective clinicians without my permission, except in cases where abuse or neglect are reported or myself/my child becomes a danger to self or others.

The Purpose of this Disclosure of Information is:

Continuity of Care Referral (indicate where):

NOTICE OF PRIVACY PRACTICES

As an agency, we have a legal duty to protect private information about you/your child.

The agency is required to protect the privacy of health information about you or your child. The agency is required to follow the procedures in this Notice.

THE AGENCY MAY USE AND DISCLOSE INFORMATION UNDER THE FOLLOWING CONDITIONS:

1. THE AGENCY MAY USE AND DISCLOSE INFORMATION ABOUT YOU TO PROVIDE SERVICES.

This may include communicating with other health care providers regarding your treatment. For example, the agency may use and disclose information if you need a referral for other health care services, or to receive authorization to begin services.

2. THE AGENCY MAY USE AND DISCLOSE INFORMATION ABOUT YOU TO OBTAIN PAYMENT FOR SERVICES.

Generally, the agency may use and give your medical information to others to bill and collect payment for the treatment and services provided to you. Before you receive scheduled services, the agency may share information about these services with your insurer to assure that services are covered.

3. THE AGENCY MAY USE AND DISCLOSE YOUR INFORMATION FOR HEALTH CARE OPERATIONS.

The agency may use and disclose information about you in performing business activities, which are called “health care operations”. These “health care operations” allow the agency to improve the quality of care we provide and reduce health care costs. Examples of the way the agency may use or disclose information about you for “health care operations” include the following:

• Reviewing and improving the quality, efficiency, and cost of care that we provide to you.
• Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.

• Cooperating with outside organizations that assess the quality of the care that the agencies and others provide. These organizations might include the Ohio Department of Mental Health and Addictions Services and the county Addictions and Mental Health Services Board.
• Resolving complaints and grievances.
• Reviewing activities and using or disclosing information in the event that control of the agency changes significantly.

4. THE AGENCY MAY DISCLOSE INFORMATION TO PERSONS INVOLVED IN YOUR CARE.

The agency may disclose information about you to a relative, or any other person you identify if that person is involved in your care and the information is relevant to your care. When the client is a minor, for instance, the agency may disclose information about the minor to a parent, guardian, or other person involved in your care if there is an emergency situation, and someone needs to be notified of your location or condition.

You may request that the agency not disclose information to persons involved in your care. The agency will generally comply with your request, unless there is an emergency or the client is a minor. If the client is a minor, the agency may or may not be able to comply with your request.

5. OTHER CIRCUMSTANCES IN WHICH THE AGENCY MAY USE AND DISCLOSE INFORMATION ABOUT YOU.

The agency may use and/or disclose information abut you for a number of circumstances in which you do not have to consent, give authorization, or otherwise have an opportunity to agree or object. These instances include:

• When the use and/or disclosure is required by law. For example, when a disclosure is required by federal, state, or local law or other judicial or administrative proceedings, or when the disclosure related to victim of abuse, neglect, or domestic violence.
• When the use and/or disclosure is for health oversight activities. For example, the agency may disclose information about you to a state or federal health oversight agency which is authorized by law to oversee agency operations or to assure the health of the public.

•  When the disclosure is for law enforcement purposes. For example, the agency may disclose information about you in order to comply with laws that require the reporting of certain types of wounds or other physical injuries, or in reporting of missing persons.

• When the use and/or disclosure is to have a serious threat to health or safety. For example, the agency may disclose information about you to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

• When the use and/or disclosure involves correctional institutions and in other law enforcement custodial situations. For example, in certain circumstances, the agency may disclose information about you to a correctional institution having lawful custody of you.

   

THE AGENCY MAY USE OR DISCLOSE INFORMATION ABOUT YOU WITH YOUR AUTHORIZATION.

Under any circumstances other than those listed above in #5, the agency will ask for your written authorization before the use or disclosure of information about you. If you sign a written authorization allowing the agency to disclose information about you in a specific situation, you can later cancel your authorization in writing. If you cancel in writing, the agency will not disclose information after receipt of your cancellation, except for disclosures which were being processed before the cancellation was received.

YOU HAVE SEVERAL RIGHTS REGARDING PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU.

YOU HAVE THE RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES OF INFORMATION ABOUT YOU. The agency is not required to agree to your requested restrictions. However, even if the agency agrees to your request, in certain situations, your restrictions may not be followed. These situations include emergency treatment, disclosures to the Department of Health and Human Services, and uses and disclosures described in the previous section of this Notice.

YOU HAVE THE RIGHT TO REQUEST DIFFERENT WAYS TO COMMUNICATE WITH YOU. You have the right to request how and where the agency contacts you. For example, you may request that the agency contact you at your work number or by email.

YOU HAVE THE RIGHT TO REQUEST TO SEE AND RECEIVE A COPY OF INFORMATION IN YOUR CLINICAL RECORD. There are certain situations in which the agency is not required to comply with your request. Under these circumstances, the agency will respond to you in writing, stating why your request is not being granted and describing any rights you may have to request a review of the denial.

YOU HAVE THE RIGHT TO REQUEST AMENDMENTS OR CHANGES TO CLINICAL, BILLING, AND OTHER RECORDS USED TO MAKE DECISIONS ABOUT YOU. If you believe that the agency has information that is either inaccurate or incomplete, information may be added to indicate the problem and notify others who have copies of the inaccurate or incomplete information.YOU HAVE THE RIGHT TO RECEIVE A WRITTEN LIST OF DISCLOSURES ABOUT YOU. You may ask for disclosures made up to six (6) years before your request (not including disclosures made prior to April 14, 2003). We are not required to include disclosures:

• For your treatment;
• For billing and collection of payment for your treatment;
  For health care operations;
• Authorized by you, or which are made to individuals involved in your care;
• Allowed or required by law when the use and/or disclosures related to certain specialized government functions;
• As part of a limited set of information which does not contain certain information which would identify you.
• The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure.

6. YOU HAVE THE RIGHT TO REQUEST ADDITIONAL PAPER COPIES OF THIS NOTICE AT ANY TIME.

7. YOU HAVE THE RIGHT TO REQUEST RESTRICTIONS ON USES

AND DISCLOSURES. You have the right to request that we limit the use and disclosure of information about you for treatment, payment, and health care purposes.

YOU MAY FILE A COMPLAINT ABOUT THE AGENCY'S PRIVACY PRACTICES. THIS WILL NOT AFFECT THE SERVICES OR TREATMENT YOU RECEIVE.

CLIENT RIGHTS AND GRIEVANCE POLICY/PROCEDURE

Whole Mind Wellness Initiative ensures that quality services are provided on a consistent basis to each individual client to allow for the resolution of grievances as presented by clients in a fair and timely fashion to provide a mechanism of reviewing decisions made by others within the agency.

Each client at Whole Mind Wellness Initiative has all of the following rights:

• The right to be treated with consideration and respect for personal dignity, autonomy and privacy;
• The right not to be discriminated against for receiving services on the basis of race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state, or federal laws;
• The right to reasonable protection from physical, sexual, or emotional abuse and inhumane
• The right to receive services in the least restrictive, feasible environment; The right to give informed consent to or refuse any service, treatment, or therapy, including medication, except in an emergency;
• The right to be informed of one's own condition;
• The right to participate in the development, review, and revision of one's own individualized treatment plan and to receive a copy of it;
• The right to participate in any appropriate and available service that is consistent with an individual service plan (ISP), regardless of the refusal of any other service, unless that service is a necessity for clear treatment reasons and requires the person's participation;
• The right to be informed of and the right to refuse any unusual or hazardous treatment procedures;
• The right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is an immediate risk of physical harm to self or others;
• The right to be advised and the right to reuse observation by others and by techniques such as one-way vision mirrors, tape recorders, video recorders, television, movies, photographs, or any other audio and visual technology. This right does not prohibit an agency from using closed- circuit monitoring to observe seclusion rooms or common areas, which does not include bathrooms or sleeping areas;
• The right to confidentiality of communications and person identifying information within the limitations and requirements for disclosure of client information under state and federal laws and regulations;
• The right to have access to one's own client record, unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction;

• The right to be informed, in a reasonable amount of time in advance, of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not
• The right to be informed of the reason for denial of a service; The right to know the cost of services, The right to consult with an independent treatment specialist or legal counsel at one's own expensive; and The right to be verbally informed of all client rights, and to receive a written copy upon request; The right to exercise one's own rights without reprisal, except that no right extends so far as to supersede health and safety considerations; The right to file a grievance; The right to have oral and written instructions concerning the procedure for filing a grievance, and to assistance in filing a grievance if requested; and The right to contact the Client's Rights Officer who can assist in lodging a grievance/complaint.

If any client or guardian feels their rights are not being fulfilled, or if they have any problem or complain, clients or guardians of clients of Whole Mind Wellness Initiative can voice any problems with any member of their care team, a supervisor, the Executive Directors, or the Client's Rights Officer.

The Client's Rights Officer is: Penny Willis, LSW

Office Phone: Cell Phone: 216-326-2472 E-mail:info@mywholemind.com

Euclid, OH 44132

Monday through Friday, 9 am to 5 pm Friday: 9 am to 4 pm Additional hours available by appointment.

If the client's problem or complaint is not resolved informally by speaking with any member of their care team, a supervisor, the Executive Directors, or the Client's Rights Officer, then the Client's Rights Officer should explain the formal grievance process to the client/guardian and allow him/her to file a client grievance/complaint form. The grievance/complaint must be put into writing. The Client's Rights Officer is available to assist a client/guardian in the filing of a grievance/complaint.

If the client/guardian cannot write the grievance/complaint on their own, they should request to speak with the Client's Rights Officer who will help them write it; or, if necessary, listen to the verbal grievance/complaint and transfer it to writing on the grievance/complaint form.

The written grievance/complaint must be dated and signed by the client, the individual filing the grievance on behalf of the client (if applicable) or have an attestation by the Client's Rights Officer that the written grievance is a true and accurate representation of the client's grievance. It is required that the grievance include, if available, the date, approximate time, description of the incident and names of individuals involved in the incident or situation being grieved.

The completed grievance/complaint form should be given to the Client's Rights Officer. It is then forwarded to the Director of Compliance, Quality Assurance, and Training.

The Director of Compliance, Quality Assurance, and Training will then conduct an investigation regarding the grievance/complaint and make the decision that is in the best interest of the client's health and medical treatment.

Should the client/guardian disagree with this decision, he/she should request a meeting with the Executive Director(s) or his designee. All information will be reviewed in the meeting with the Executive Director(s) or their designee. The Executive Director(s) or designee shall make a decision after the meeting and document his/her decision. The decision of the Executive Director(s) is final.

Whole Mind Wellness Initiative will make a resolution or decision on all grievances within twenty (20) business days of receipt of the grievance. If there are any extenuating circumstances that indicate that this time period will need to be extended, these circumstances must be documented in writing in the grievance file and written notification of the extension given to the client or client's guardian.

Clients or their guardians must receive a written acknowledgement of receipt of the grievance within three (3) business days from receipt of the grievance. The written acknowledgement shall include, but not be limited to, the following:

Date the grievance was received A summary of the grievance An overview of the grievance process A timetable for completion of an investigation and notification of resolution, and The Client's Rights Officer's contact name, address, telephone number, and email.

Clients or their guardians also have the option to file a grievance with outside organizations that include, but are not limited to, the following:

Cuyahoga County Board of Alcohol, Drug Addiction, and Mental Health Services 2012 W. 25ᵗʰ St. 6ᵗʰ Floor Cleveland, OH 44113 (216) 241-3400 adamhscc.org

Ohio Department of Mental Health and Addiction Services 30 E. Broad St. 36ᵗʰ Floor Columbus, OH 43215 (614) 466-2596 mha.ohio.gov

Disability Rights Ohio 200 Civic Center Dr.

U.S. Department of Health and Human Services

Civil Rights Regional Office - Midwest

Columbus, OH 43215 (614) 466-7264 disabilityrightsohio.org

233 N. Michigan Ave. Suite 240 Chicago, IL 60601 (800) 368-1019 hhs.gov

If you think your privacy rights have been violated, you may send a written complaint to the Department of Health and Human Services at:

Office for Civil Rights US Department of Health and Human Services 200 Independence Ave, SW Room 509F, HHH Building Washington, DC 20201

IF YOU FILE A COMPLAINT, WE WILL NOT TAKE

ANY ACTION AGAINST YOU OR CHANGE YOUR TREATMENT IN ANY WAY.

Mental Health Emergency Information

If you experience a mental health emergency during business hours, please call your clinician directly. Some emergency circumstances may occur when your clinician is unavailable and therefore unable to respond. On these occasions, please contact our office at (216) 342-4445, Monday through Friday, 9 am to 4:30 pm.

A Supervisor on Call is available to assist you with mental health emergencies in the early evenings, Monday through Friday, 5 pm to 8 pm, by calling (216) 219-3960.

Outside of these hours, please call 911 or go to your nearest emergency room. You may also call Mobile Crisis located in your county using the following contact information:

Summit Cuyahoga County Mobile Crisis Adults: via FrontlinePortage Path ServiceSupport Hotline (216)623-6888 (330)434-9144

Lake County County Lake CountyThe Nord Crisis Hotline Center Crisis

Mahoning County Crisis Hotline (330)747-2696

Hospital Emergency Line (330)543-7472