Consent for Treatment and Services

                                    CONSENT FOR TREATMENT AND SERVICES
 
Persons seeking outpatient mental health treatment can expect the following information from the clinic when they enroll:
 
1.  The results of the assessment have been presented verbally and in writing on the Initial Assessment and Treatment Plan and questions have been answered.
 
2.  The purpose of treatment has been explained.
 
3.  Treatment alternatives have been discussed, or an opportunity has been offered.
 
4.  Possible outcomes and side effects, or drawbacks, of the treatment offered have been discussed.
 
5.  The treatment recommendations have been offered, including the benefits of treatment.
 
6.  The approximate duration and the desired outcomes of treatment have been explained.
 
7.  The rights of the consumer have been presented, including the consumer’s responsibilities in the development and implementation of the treatment plan.
 
8.  The services being offered have been identified by name, and the basic features of that treatment have been described.
 
9.  The fees have been explained and the consumer has consented to the financial obligation incurred upon entering services as stated on the Financial Agreement Form.
 
10.  Information on how to use the clinic’s grievance procedure has been offered.
 
11.  The means by which a consumer may obtain emergency mental health services during periods outside of normal operating hours of the clinic have been explained.
 
12.  The clinic’s discharge policy has been presented, including what happens when a person fails an appointment or cancels late (less than 24 hours notice), or fails to make payments for services.
 
Your signature below indicates that the information identified above has been presented to you, and that your questions have been answered.  Your treatment plan may be modified at any time upon your request, or if circumstances change.  This consent will be in effect for a maximum of 15 months, and can be renewed at that time or before.
 
_____________________________/____________________________       __________
Patient Signature (include parent/guardian signature when applicable            Date       


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