Mental Health Consent Form Packet

For Minor Clients in Parents’ Custody:     

The minor client has another parent who must consent to treatment as well and can be contact at:

LIMITS TO CONFIDENTIALITY/PRIVACY:  I understand that all information about the above-named client is considered private and will not be shared with anyone without my consent, except under the following circumstances:

• A Core Connection is required to report suspicion of child/elder/disabled adults abuse & neglect
• A Core Connection is required to release information for the purpose of abuse/neglect investigations
• A Core Connection is allowed to warn potential victims if we believe that their lives are in danger
• A Core Connection is required to release a copy of records and/or testimony if subpoenaed in court.
  Even with your consent,
• A Core Connection will share only the information that is necessary for assessment, coordination of treatment, notification to those responsible for mandated treatment, or other specified purposes as described in the PCP Notification and Release of Information forms

 STATEMENT OF AUTHORITY TO CONSENT:  I certify that I have the legal authority to consent to mental health treatment, release of information, and all legal issues involving the above-named client.  If my status as legal guardian should change, I will immediately notify A Core Connection of the name, address, and telephone number of the person who has assumed guardianship of the above-named client.

 CONSENT FOR TREATMENT AND TREATMENT LOCATION: I consent for the above-named client to participate in mental health assessment and treatment through A Core Connection, including sharing relevant confidential information with those involved in services.

FUNDING AUTHORIZATION:  I authorize A Core Connection to release relevant confidential information to my current funding source in order to process claims, obtain reimbursement, and comply with the funding source’s auditing requirements. I understand that I will be responsible for any charges that this funding source does not cover, including any services provided after my insurance has lapsed, fees described on the Copayment Agreement, and fees described in the No Show/Cancellation Policy.

 I understand that I may revoke consent for the above at anytime, however, I cannot revoke consent for action that has already been taken. By signing below, I acknowledge that I have carefully read and reviewed all information contained in the attached consent packet, including all outlined pages. I understand the nature of the services, policies, and procedures described therein. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily consent to the services and agree to comply with the guidelines and terms presented. I understand that this consent packet is valid for one year from the date signed, unless otherwise specified or revoked in writing. After one year, the consent will expire, and a new consent will be required to continue services.

Dear Client and Family,

Thank you for welcoming us into your home for mental health services. To help create a safe, comfortable, and productive environment, we kindly ask that all clients and household members follow the expectations below:

1. Privacy & Space
Please provide a quiet area free from distractions (TV, phones, other conversations) so sessions can remain focused, confidential, and effective.

2. Safety
All pets should be secured if they may interfere with the session. We also ask that the environment be free of any hazards to ensure everyone’s safety.

3. Participation
Please be present, engaged, and prepared at the scheduled session time. For youth, a parent or caregiver may be asked to participate when clinically appropriate.

4. Respectful Environment
We ask that the home environment is calm, respectful, and appropriate for therapeutic work. This includes avoiding profanity, conflict, or interruptions during sessions.

5. Cancellations & Scheduling
If you need to adjust a session, please notify your therapist as early as possible so we can best support your family’s needs and maintain continuity of care.

These expectations help us create the best possible therapy experience and support positive outcomes. We appreciate your cooperation and look forward to working together.

Client Rights & Responsibilities
At A Core Connection, we want you and your family to understand what to expect from services, your rights, and how we can work together to make treatment successful.

What You Can Expect
Services will focus on your individual needs and may include family or caregiver participation when appropriate. The frequency and length of services will depend on your needs, treatment recommendations, progress, and insurance requirements.
You will complete an initial assessment and work with your clinician to develop goals for treatment. Your progress and treatment plan will be reviewed regularly with you and/or your parent or guardian. We may ask for feedback about your experience so we can continue improving our services.
When services end, your clinician will help with discharge planning, recommendations, or referrals when needed.

Your Rights
Be Treated with Respect: You and your family will be treated with dignity, courtesy, and respect. Be Free from Discrimination: Services will be provided without discrimination based on age, disability, race, sex, ethnicity, religion, culture, or other protected status. Make Choices About Your Care: You may ask questions, participate in treatment decisions, request another provider, decline referrals, or choose to discontinue services.
Privacy & Confidentiality: Your information will be kept private and shared only with your permission, except when disclosure is required by law, such as suspected abuse or neglect, safety concerns, or a court order. Access Your Records: You may request access to or copies of your records. Certain limitations or fees may apply.
Voice Concerns: You may make a complaint or grievance without fear that it will negatively affect your services. Be Safe: You have the right to receive services in an environment free from abuse, neglect, exploitation, or unnecessary harm.
To report suspected abuse, neglect, or exploitation, contact the Florida Abuse Hotline at 1-800-96-ABUSE (1-800-962-2873).

Your Responsibilities
Attend scheduled appointments and provide notice when you need to cancel or reschedule.
Participate in treatment and work toward the goals developed with your clinician.
Keep us informed of changes to your contact or insurance information.
Pay any applicable copayments, deductibles, or other amounts not covered by insurance.

Our Responsibilities
Treat you and your family professionally and respectfully.
Provide appropriate, quality services based on your individual needs.
Maintain accurate and confidential treatment records.
Communicate with you regarding significant scheduling changes whenever possible.
Assist with referrals or transition planning when additional services are needed.
Services may be discontinued when treatment goals have been met, services are no longer clinically appropriate, or participation requirements are not being met. When appropriate, we will assist with recommendations or referrals for continued care.

Questions or Concerns
If you have questions, please contact A Core Connection at 407-789-CORE.

If you have a complaint or grievance that cannot be resolved with your provider, please contact the Operations Director or Clinical Director. Your concern will be reviewed and responded to within 2 business days.

Crisis & Emergency Assistance
If you are experiencing a crisis and your clinician is unavailable, call the Crisis Hotline at (407) 425-2624.

If there is an immediate danger to yourself or someone else, call 911 or go to the nearest emergency room.

At A Core Connection, your health and safety are important to us. This handout provides basic wellness tips and explains what to expect if a health, safety, or emergency situation occurs during services.

Healthy Habits
Taking care of your physical and emotional health can help you feel your best. We encourage you and your family to:

Practice good hygiene: Wash your hands regularly, bathe as needed, brush your teeth, and keep your living space clean.
Get enough sleep: Maintain a healthy and consistent sleep routine appropriate for your age.
Eat well: Choose a balanced diet that includes fruits, vegetables, and other nutritious foods.
Stay active: Regular physical activity supports both physical and emotional health.
Take care of your emotional health: Spend time doing things you enjoy, connect with supportive people, and ask for help when you need it.
Make healthy choices: Talk with a healthcare provider about pregnancy prevention, sexual health, medications, or other health concerns when appropriate.
A Core Connection's Health & Safety Policies
Abuse & Neglect: Our staff are required by law to report suspected abuse, neglect, or exploitation of children, elderly adults, or vulnerable adults.
Safety Concerns: If we believe someone is in immediate danger of seriously harming themselves or another person, we will take appropriate steps to protect everyone's safety. This may include contacting emergency services.
Tobacco & Vaping: Smoking, vaping, and tobacco use are not permitted inside our offices. Staff will not use these products in the presence of clients.
Drugs & Alcohol: Clients and others participating in services should not be under the influence of alcohol or recreational drugs during sessions. A session may be ended or rescheduled if participation cannot safely continue.
Medications: If medication causes significant impairment that makes it unsafe or difficult to participate in services, the session may need to be rescheduled.
Weapons: Weapons are not permitted in A Core Connection offices. During in-home services, firearms and other weapons must be safely secured and inaccessible.
Advance Directives: If you have an advance directive that may be relevant to your care, please provide a copy for your record.
Emergency Procedures
Threatening or Dangerous Behavior: Staff will use appropriate de-escalation and safety procedures. 911 may be called if there is an immediate danger to the client, family, staff, or others.
Medical Emergency: Staff will call 911 when emergency medical assistance is needed and follow instructions from emergency personnel.
Severe Weather: Sessions may be cancelled, ended early, or rescheduled when weather conditions make travel or services unsafe. Please follow local emergency and weather guidance.
Power Outages or Building Emergencies: Services may be cancelled or rescheduled when the building cannot safely support services.
Emergency Equipment: A Core Connection maintains appropriate safety equipment, including first-aid supplies and fire extinguishers, at our office locations.
Remember
For an immediate medical or safety emergency, call 911.

Physician’s office:

FOR NOTIFICATION PURPOSES ONLY -- DO NOT SEND RECORDS 

This document serves as notification to the Primary Care Physician that counseling and/or behavior analysis services are being provided by

A Core Connection Services and Consulting, LLC.

Acknowledgement: By signing below, I authorize A Core Connection to release a copy of this document to the PCP named above.  I further authorize exchange of confidential information between the PCP and A Core Connection for the purpose of coordination of care.  Contact information for A Core Connection is as follows:

587 East State Road 434 Suite 3033  Longwood, FL  32750 OR 
2886 South Osceola Ave  Orlando, Fl  32806
(407) 789-CORE Office  (407) 612-2359 Fax

 I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from A Core Connection.

I understand that I may revoke this authorization in writing at any time, however I cannot revoke authorization for action that has already been taken.

A copy of this release shall be valid as the original.     

THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.

Regular attendance at scheduled appointments is very important.  Our services will not be effective in helping you if you do not keep your appointments.  Irregular attendance, especially a “no show,” is also inconvenient and costly for the staff assigned to help you.  It is therefore your responsibility to attend all scheduled appointments. 

CANCELLATION POLICY: If you call your assigned clinician at least an hour before your scheduled appointment, it is considered a “Cancellation,” although 24-hour notice is preferred.

• After the first cancellation, the staff person will call you to reschedule.
• After two cancellations in a row, you must call him/her if you desire to continue services.
• After the third cancellation in a row, services will be terminated.
• If you cancel three times, with some attendance in between each cancellation, your therapist will discuss with you some possible solutions to the problem of irregular attendance. 

NO SHOW POLICY: If you do not call to cancel at least an hour before the scheduled appointment time, it is considered a “No Show.”

If you fail to notify your assigned clinician prior to a missed in-home session, you will be charged a $20 travel fee to cover the staff cost of traveling to your home for the missed appointment.

• If you fail to notify your assigned clinician prior to an in-office or in-school session, you may be charged a $20 travel fee if the staff traveled to that location specifically for that session.
• After the first “No Show,” the staff person will call to reschedule the appointment and you will be required to pay the fee.
• After the second “No Show,” services will be suspended, and you are required to pay the travel fees for both missed sessions (if first one still not paid) in order to reinstate services
• After the third “No Show,” your case will be closed. If these services are mandated or court-ordered, the person responsible for monitoring compliance with the mandate (e.g., dependency case manager, probation officer) will be notified of repeated cancellations/no shows and suspension or termination of services.

I understand A Core Connection’s No Show/Cancellation policy and understand that regular attendance is necessary for treatment to be effective.  Therefore, I agree to attend all scheduled sessions.  If I cannot keep an appointment, I will call the staff 24 hours in advance to reschedule.  If I have an emergency that prevents me from attending, I will call the assigned clinician at least one hour before the appointment to cancel.

THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.

I hereby consent to participate in telehealth services with, A Core Connection Services and Consulting, as part of my psychotherapy. I understand that telehealth is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to telehealth health:

1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required.

6) I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within two minutes, please call me to discuss other options.  

7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. Emergency Protocols I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life- threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.

I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction. 

I understand that I may stop telehealth services at any time and request in-person services when available. I also understand the potential benefits of telehealth, including access to care, convenience, and reduced travel time.