I,

agree to:

, and to contact Beautiful Minds Medical staff if unable to attend.

2. Make my own arrangements for transportation to and from the facility. I agree to arrive on time and leave at the end of the program day. I will inform staff of any need to leave early and notify staff in advance of any anticipated absences. Frequent absences or leaving group/activities early on a regular basis will result in review of my continued participation in the program. If I am on facility-provided transportation, I will follow all rules for the van. 

 

3. Cooperate with staff and participate, to the best of my ability, in all activities and group scheduled for me.

 

4. a) Not use or possess street drugs or alcohol before or during program hours.

    b) Attend meeting:

5. Refrain from making physical or verbal threats to people or property, such as name calling, put-downs, threating with objects, threatening bodily harm or property destruction.

 

6. Remain in the facility during program hours unless other arrangements have been made with staff.

 

7. My rights as a patient have been described to me by staff. Failure to comply with the rules will result in review of treatment with staff, suspension and/or discharge from the program.

 

8. Refrain from assaultive behavior toward others or destructive behavior toward myself, for example, cutting myself or overdosing on medication. If I am at risk of hurting myself or others during the program attendance I agree to tell staff.

 

9. I

, hereby acknowledge that I have received this Notice of Privacy Practices, with an effective date of June 1, 2013. Within these guidelines, at Beautiful Minds Medical, specifically there are five instances in which your right to privacy will be set aside:

A. Your therapist is required by law to report if any participant in therapy, specifically or vaguely disclose(s) information possibly indicating current or past abuse or neglect of a child, dependent adult, or elder.

B. Your therapist must notify the local authorities and/or the person(s) in danger if your therapist believes, from information that you disclose, that you are of danger to yourself or to someone else.

C. During court proceedings, the Judge’s ruling supersedes your right to confidentiality. The attorney may subpoena your records, take your therapist’s deposition, have your therapist appear in court, or all three. Your therapist must break confidentiality if the Judge makes such an order.

 

And, only if in the Intensive Outpatient Program (IOP):

A. Beautiful Minds Medical works within a Treatment Team model to provide an integrated approach to the overall needs of the client. In accordance with this model, information and behavior during group and/or individual and/or family session may be shared with the Beautiful Minds Medical Treatment Team (i.e., Psychiatrist, Nurse Practitioner, and Therapist). The information is shared for the purpose of treatment planning to best meet your therapeutic needs. 

 

If I am at risk of hurting myself or others while away from the program, I will call: