Please circle the number which best identifies your response to each corresponding question -
1. Never or Almost Never
4. Very Often
5. Always or Almost Always
It is the policy of this clinic that each patient, or individual acting on behalf of the patient, will receive specific, complete, and accurate information regarding the psychotherapy or other treatment they receive at all of our clinic locations. It is our agency's policy to offer this information in both verbal and written form. All patients will be provided and should take, the necessary time to review this informed consent policy prior to the onset of treatment. You may also ask for additional information from your therapist regarding any particular treatment at any time during the course of treatment.
Completed and accurate information must be provided concerning each of the following areas:
1. The benefits of the proposed treatment.
2. The way in which the treatment will be administered, the treatment schedule, and my involvement in the development of my treatment plan.
3. The expected side effects of the treatment and/or risks of side effects from medications.
4. Alternative treatment modalities.
5. The probability of consequences of not receiving treatment.
6.The consequences of the continued use of alcohol or other drugs, unauthorized absences, or any other evidence of noncompliance.
7. My financial obligations regarding my treatment cost.
8. Information regarding sexually transmitted diseases and communicable diseases.
9. The time period for which the informed consent is effective.
10. Your rights as a patient to withdraw the informed consent at any time in writing.
11. Hope for a Better Tomorrow provides mental health services at our facility. Mental health staff may be involved in your treatment planning and referrals may be made.
12. Client records are kept securely for mental health patients.
13. I understand that this informed consent is good for the course of treatment
14. I understand that this informed consent is to expire in 15 months.
15. I understand that I can withdraw my consent, in writing, at any time.
My signature indicates that (1) I have read and I understand the above policy and procedures pertaining to my granting of informed consent for the treatment which I choose to receive and (2) that I have been presented with the necessary and appropriate information either verbally or in writing, and that I have also had adequate time to consider this information, and that I do hereby give my informed consent to participate in the recommended treatment. I have also received a copy of this document.