CONSENT FOR OUTPATIENT TREATMENT CONSENT FOR OUTPATIENT TREATMENT Please enable JavaScript in your browser to complete this form.Client Name: Client:Single Line TextI, the undersigned Patient, Parent, or legal guardian hereby give my consent for and acknowledgment of the following items which are initialed: I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to provide within: (1) the scope of the provider’s license, certification, and training; or (2) the scope of the license, certificate, and training of the behavioral health care providers directly supervising the services received by the patient. If the patient is under the age of eighteen or unable to consent to treatment. I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent for treatment on behalf of the individual.Patient Rights.Receipt or patient Rights. Patient Rights. 1I understand the possible psychology risk involved in counseling I am hereby forewarned and cautioned, that engaging in psychotherapy may involve discussing uncomfortable past traumatic events, and /or experiencing depression, anger, anxiety, and other difficult intense emotions. Patient Rights. 2I understand that I cannot attend any session or group while I am under the influence of illegal drugs and/or alcohol. Patient Rights. 3I understand that my therapist may work with the typist, practicum student’s supervisor, and case managers regarding my treatment and /or clinical files. Patient Rights. 4I understand that certified alcohol and drugs abuse counselors, practicum students/interns, and unlicensed professionals do not have privileged communication and may be required if court ordered to testify regarding my treatment. Patient Rights. 5I understand that I have the right to receive Telehealth services which are available for most insurance plans and are offered through HIPAA-compliant, confidential software. Patient Rights. 6I understand that I need to communicate any concerns or problems I have to my therapist regarding my treatment and that I am responsible to make change occur. I understand that I am responsible for completing tasks/homework assigned by my therapist. I have read and understand the above-initiated items and received an explanation of the information. Patient Rights. 7I have read and understand the above initialed items and received an explanation of the information. Date: Person Served Signature: Witness:Authority of Personal Representative: Date: Personal Representative: Submit
