CONSENTS/RIGHTS INFORMATION
Consent for Treatment
I hereby give my consent for Therapist to provide mental health services to me/my child. I have been informed of the scope and purpose of the service, and understand that I may withdraw my consent at any time. I understand I may also refuse any services offered at any time.
2. Financial Release
I understand that Therapist may use confidential information about me to bill and be paid for services. I hereby consent for Therapist to release information to the billing agent, Integrity Support, Inc. and its contracted clearinghouse, and/or to the funding source, and for the funding source to release information to Therapist and Integrity Support, Inc. for this purpose.
3. Permission to Transport
I hereby grant permission for Therapist, to provide transportation to my child, and agree to hold Therapist harmless for any accident/injury that results from the provision of transportation.
4. Permission to Seek Emergency Medical Care
I hereby give consent for Therapist, to seek and sign consent for emergency medical care in the event that I am unable to do so for myself. It is understood that Therapist will attempt to locate me, or another legally responsible adult, as quickly as is possible in the emergency situation.
5. Client Rights/Grievance Policies (See Handout)
I have received and had explained to me the Client Rights handout. Therapist gave me this handout and verbally explained my rights as a client.
6. Privacy Rights (See Handout)
I have received and had explained to me the Privacy Rights handout. Therapist gave me this handout and verbally explained my rights concerning the privacy of information as a client. I understand these rights are designed to protect my privacy.
