Informed Consent, Patient Services, and Financial Agreement
This document contains important information about our professional services and business policies. Please read it carefully and discuss any questions with your provider.
1Consent to Treatment
By signing the consent form, you authorize us to provide mental health services that your provider determines are appropriate for your treatment.
You have the right to ask questions about any treatment or procedure.
You have the right to refuse any treatment or procedure.
Your consent is voluntary and can be withdrawn at any time.
2Confidentiality
The information you share with your provider is confidential and will not be disclosed without your written authorization, except as required or permitted by law.
Exceptions to confidentiality include: imminent danger to yourself or others, suspected abuse or neglect of a child, elderly, or disabled person, court orders, and other situations as required by law.
We may consult with other professionals about your case to provide the best care. In such cases, your identity is protected to the extent possible.
3Treatment Approach
Your provider will work with you to develop an individualized treatment plan based on your needs and goals.
Treatment may include individual therapy, group therapy, medication management, or other services as appropriate.
The length of treatment varies depending on your individual needs and progress.
You are encouraged to actively participate in your treatment and communicate openly with your provider.
4Risks and Benefits
Mental health treatment has both potential benefits and risks. Benefits may include improved mood, relationships, and coping skills.
Risks may include experiencing uncomfortable feelings such as sadness, guilt, anxiety, or anger.
There is no guarantee of specific outcomes from treatment.
Your provider will discuss specific risks and benefits related to your treatment plan.
5Emergency Procedures
If you are experiencing a mental health emergency, please call 911 or go to your nearest emergency room.
The National Suicide Prevention Lifeline is available 24/7 at 988.
Your provider may not be available outside of regular business hours for emergencies.
Contact Information
If you have questions about this notice or any of the information on this page, our team is happy to help.
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Need Clarification?
If you have questions about this notice, our team is happy to help.