By Signing below, I request and voluntarily consent to receive mental health services from Alaska Behavioral Health (Organization). and its mental health staff. Such care may include routine diagnostic procedures and/or related services that the mental health staff may recommend as medically necessary. No guarantees have been made to me by the Organization as to the result of services or evaluation.
I understand that as part of my healthcare, this Organization originates and maintains health records that are used for Treatment, Payment and Health Care Operations.
With your permission we may ask to record your session to provide quality feedback, supervision to your clinician and to improve overall quality of our care to you. This recording is kept in a secure location until it has been reviewed by a supervisor and then it is stored in a secure location. I understand that my session with my therapist after obtaining my permission may be recorded for quality purposes.
Consent for Data Collection
You are choosing to receive services at Alaska Behavioral Health. Your participation and sharing information will help us better serve our communities in Alaska. The data we provide to the Substance Abuse and Mental Health Services Administration (SAMHSA) is not individually identifiable by them.
This form provides information so you can make an informed decision about your participation. Please read this form carefully and ask questions if you have them.
What is the purpose of the data collection?
Alaska Behavioral Health is partially funded by the United States Department of Health and Social Services/Substance Abuse and Mental Health Services Administration (SAMHSA). As part of this funding, SAMHSA requires Alaska Behavioral Health to collect and report information on all individuals served at our Organization to evaluate program effectiveness. If you choose to participate, the information you provide will help us improve our services.
What Information will I be asked to provide?
If you agree to participate, we will collect information in a face-to-face structured interview with you when you begin receiving services, every six months you remain in services, and when you leave services. The structured interview will use the SAMHSA National Outcome Measures (NOMs), Client-level Measures for Discretionary Service Programs Providing Direct Services Tool, child or adult version.
Demographic information will be obtained at the first interview including gender, ethnicity, race, and month and year of birth. At each interview, participants will be asked questions regarding:
Military Family and Deployment
Violence and Trauma
Crime and Criminal Justice
Perception of Care
How will my privacy be protected?
Information collected by Alaska Behavioral Health staff during the structured interview will be entered into a secured SAMHSA database called Performance Accountability & Reporting System (SPARS). SPARS is a password protected, web-based system for reporting information on SAMHSA funded programs. Your name will not be provided to SAMHSA. Instead, your information will be identified with a number assigned by Alaska Behavioral Health staff. This number does not include any part of your name, date of birth or social security number. This ID number is designed to track a specific recipient through his/her interview(s) while maintaining anonymity.
How will the information be used?
The primary purpose of data collection is to improve services at Alaska Behavioral Health. Your clinician will review the results with you to help plan ongoing services. Additionally, your responses will be used to determine the effectiveness of services at Alaska Behavioral Health. The results of clinic-wide analyses may be used to report about program services.
SAMHSA uses aggregate data to conduct performance evaluation of federally funded programs. Aggregate data refers to de-identified information that is collected from multiple sources and combined into summary reports, typically for the purpose of public reporting or statistical analysis. With aggregate data sets, it is not possible to identify the information that has been provided by any given respondent.
What are the potential risks of my participation?
The primary risks of participation include potential discomfort with answering questions about sensitive issues and the possibility that someone you have not authorized could gain access to your protected health information. With respect to the first risk, Alaska Behavioral Health makes every effort to provide a safe and supportive therapeutic environment. Your clinician will be available to provide assistance and has been trained in ways to discuss sensitive and personal information. Additionally, if you choose to participate, you have the right to refuse to answer any question(s). With respect to the second risk, Alaska Behavioral Health has strict policies and procedures in place to comply with state and federal laws protecting the confidentiality of health information and substance use. Your information is not able to be individually identified by SAMHSA, rather the information is assessed as a whole.
What are the potential benefits of my participation?
Your participation will help Alaska Behavioral Health improve services for individuals and families in our community. It will also provide you with important information about your well-being that will facilitate treatment and discharge planning.
Your participation is voluntary:
Your participation in the evaluation is voluntary. If you decide not to participate in the data gathering, you will not be denied services and treatment will not be affected. Additionally, if you and/or your child choose to participate, you are free to withdraw your consent/assent and discontinue participation at any time without this decision affecting your care and treatment with Alaska Behavioral Health.
What if I have questions?
You will receive a copy of this consent/assent form for your records. If you have questions about the evaluation you can discuss these with your clinician or Pamela Kennedy, Privacy Officer for Alaska Behavioral Health. They will be happy to answer your questions or discuss any concerns.
Pamela Kennedy, LPC-S, CHPC
Chief Patient Experience Officer
I have been allowed the opportunity to ask questions concerning any and all aspects of this evaluation and the procedures involved. I understand that the evaluators and the program staff have set up procedures to protect the confidentiality of records related to my involvement. I consent to the use and disclosure of my records by Alaska Behavioral Health as described above, and to the disclosure of information to SPARS and SAMHSA. I understand that I can choose not to participate in data gathering or revoke consent at any time, and that if I do so I will not be denied services or benefits.
I understand that my alcohol and/or drug treatment/rehabilitation records (if any) are protected under the Health Insurance Portability Accountability Act of 1996 (HIPAA), and its enacting regulations, and that, depending on the nature of the record and treatment involved, my records may also be protected under the federal regulations governing confidentiality of substance use disorder patient records, 42 C.F.R. Part 2. I understand that only health information covered by 42 C.F.R. Part 2 (i.e., alcohol and drug use or treatment) will continue to be protected by law from redisclosure once it leaves Alaska Behavioral Health. However, if the information is covered only by HIPAA, it is subject to redisclosure by the recipient and may no longer be protected. I understand that my records that are subject to HIPAA cannot be disclosed beyond what is permitted under this consent, unless otherwise permitted by law.
This consent shall not expire until six (6) months after I complete services with Alaska Behavioral Health, or until I revoke this consent, whichever occurs earlier. If I revoke this authorization, I must do so in writing and present my written revocation to Alaska Behavioral Health for general medical records. This revocation will not apply to information that has already been released in response to this authorization.