I,

have been assessed by Beautiful Minds Medical, Inc. for admission into the Intensive Outpatient Program (IOP) and have been informed that I may attend the IOP program. I understand that my start date is contingent on authorization  from my insurance company or, if self-pay, after I have been approved by the financial  department. 

 

I understand that this is a voluntary program and that I have been notified that my acceptance into the program has been approved. I also understand that the staff at Beautiful Minds Medical, Inc. will be expecting me to attend. If for any reason, I change my mind and do not wish to attend, I will call the program office at (530) 889-8780 prior to my start date and inform them of this decision.

 

I agree to notify Beautiful Minds Medical, Inc. by calling (530) 889-8780 ext. 113 if I am not able to attend a session. A staff member from Beautiful Minds Medical, Inc. will attempt to contact me if I do not call or attend any scheduled session. I am aware that if the staff member cannot reach me, he/she may call my provided emergency contact. If the staff member cannot reach the emergency contact, he/she may call the Police Welfare Check to check on me at my home address.  I also understand that if I do not show up for three or more  sessions (unexcused), I will be automatically discharged from the program.