ALLIED COMFORT N CARE - Consent for Treatment

ALLIED COMFORT N CARE - Consent for Treatment
OUTPATIENT MENTAL HEALTH CLINIC
236 W ALLEGHENY AVE
PHILADELPHIA, PA 19133-3629
215-989-1771
admin@alliedcomfortncare.com
CONSENT FOR TREATMENT
INFORMED CONSENT FORBEHAVIORAL HEALTH SERVICES
PATIENT INFORMATION
PURPOSE OF SERVICES
Patient Name:
Behavioral health services are intended to assist individuals in improving emotional, psychological, behavioral, and social functioning. Services may involve discussing sensitive personal information and addressing emotional challenges.
Date of Birth:

MonthDayYear
Date
NATURE OF SERVICES
Parent/Guardian (if applicable):
Services may include:
- Diagnostic assessment
- Psychotherapy
- Psychiatric evaluation
- Medication management
- Treatment planning
- Behavioral interventions
- Psychoeducation
- Crisis intervention
- Referral services
No guarantees can be made regarding specific outcomes or results from treatment.
Date:

MonthDayYear
Date
CONSENT FOR MENTAL HEALTH TREATMENT
RISKS AND BENEFITS
I voluntarily consent to receive behavioral health services from Allied Comfort & Care Outpatient Mental Health Clinic.
I understand that services may include:
- Mental health assessments and evaluations
- Individual therapy
- Family therapy
- Group therapy
- Psychiatric evaluations
- Medication management
- Treatment planning
- Crisis intervention services
- Care coordination and referrals
- Telehealth services (if applicable)
I understand that participation in treatment is voluntary and that I may withdraw my consent at any time by providing written notice. I understand that withdrawal of consent may affect my ability to continue receiving services.
Potential Benefits
- Improved emotional well-being
- Better coping skills
- Enhanced relationships
- Improved daily functioning
- Reduced symptoms of mental health conditions
Potential Risks
- Emotional discomfort
- Increased awareness of difficult experiences
- Temporary worsening of symptoms
- Stress related to discussing personal issues
- Changes in relationships resulting from personal growth
PATIENT RIGHTS
MEDICATION SERVICES
I understand that I have the right to:
- Be treated with dignity and respect
- Participate in treatment planning
- Ask questions regarding treatment recommendations
- Refuse treatment to the extent permitted by law
- Receive services free from discrimination
- File grievances without retaliation
- Review my treatment records as permitted by law
- Confidential treatment except as required by law
If medication management services are provided:
- Benefits and risks of medications will be discussed
- Alternative treatment options will be reviewed
- Questions regarding medications will be answered
- Participation in medication treatment is voluntary
CONFIDENTIALITY
TELEHEALTH SERVICES (IF APPLICABLE)
I understand that information obtained during treatment is confidential and protected by federal and state laws.
I understand that confidentiality may be broken under the following circumstances:
- Risk of harm to self
- Risk of harm to others
- Suspected abuse or neglect of a child, elder, or vulnerable adult
- Court order or legal mandate
- Medical emergencies
- Other situations required by law
I understand that telehealth services may involve:
- Video conferencing
- Telephone communication
- Electronic exchange of information
Potential risks include:
- Technology interruptions
- Unauthorized access despite security measures
- Technical failures
I understand that I may request in-person services when available.
CONSENT
PATIENT RESPONSIBILITIES
I have read and understand the information above. I voluntarily consent to receive treatment from Allied Comfort & Care.
I agree to:
- Provide accurate information
- Participate honestly in treatment
- Inform providers of changes in symptoms or medications
- Attend scheduled appointments
- Notify the clinic if I cannot attend an appointment
Patient Signature:
Date:

MonthDayYear
Date
EMERGENCY SERVICES
Parent/Guardian Signature:
Date:

MonthDayYear
Date
I understand that Allied Comfort & Care is not a 24-hour emergency service provider.
In case of an emergency, I will:
- Call 911
- Go to the nearest emergency room
- Contact the 988 Suicide & Crisis Lifeline
Witness/Staff Signature:
Date:

MonthDayYear
Date
CONSENT AND ACKNOWLEDGMENT
I have had the opportunity to ask questions about behavioral health services. My questions have been answered to my satisfaction. I understand the nature, risks, benefits, limitations, and alternatives of behavioral health treatment and voluntarily consent to participate.
Patient Signature:
Date:

MonthDayYear
Date
Parent/Guardian Signature:
Date:

MonthDayYear
Date
Compassionate Care. Empowering Wellness. Supporting Recovery.
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ALLIED COMFORT N CARE - Consent for Treatment

OUTPATIENT MENTAL HEALTH CLINIC

CONSENT FOR TREATMENT

INFORMED CONSENT FORBEHAVIORAL HEALTH SERVICES

PATIENT INFORMATION

CONSENT FOR MENTAL HEALTH TREATMENT

PATIENT RIGHTS

CONFIDENTIALITY

CONSENT

CONSENT AND ACKNOWLEDGMENT