Please provide the following information and answer the questions below. Please note: the information you provide here is protected as confidential information. Please fill out this form and bring it your first session.
Name of parent or guardian (if under 18 years old):
E-Mail:No May we email you? *Please note: E-Mail correspondence is not considered to be a confidential medium of communication.
Privacy and Rights Acknowledgement
By signing below, / am acknowledging that / have read and understood the above policies. Paper or electronic copies can be obtained per request.
Payment Acknowledgement Agreement
By signing below, I understand and agree to the above statements. / authorize my insurance benefits to be paid directly to Hope for a Better Tomorrow.
At Hope for a Better Tomorrow, you will participate in the development of your treatment plan. The treatment plan is your "map of care" which includes specific goals that you wish to accomplish. With your therapist, you will discuss frequency of treatment and what types of services and modalities will help you reach your goals.
Therapists at Hope for a Better Tomorrow strive to deliver the best possible care for their clients. In order to uphold this high standard, we ask for your signature to acknowledge that you have played an active role in the treatment planning process.
If you have further questions regarding this form, please consult with your therapist.
Please indicate 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. Allpatients 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 from 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 treatment14. 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 alsohad 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.
Clinicians at Hope for a Better Tomorrow strive to deliver the best possible care for their clients. In order to uphold this high standard, we ask for permission to notify your primary care physician and/or psychiatrist. By signing this form, it gives your Hope for a Better Tomorrow therapist permission to contact your primary care physician and/or psychiatrist to introduce themselves as your behavioral health care practitioner and work directly with them when necessary (for example- strategiesfor better medication management, coordination of care, and treatment recommendations).
Authorization to Disclose Information To the patient: Disclosure of the above information is for coordination of care between your physician and your behavioral health provider(s The information released on this form is part of your protected health information and is protected under federal law. Releasing this information to your physician is strictly voluntary and does require your written consent for this form to be sent, it does not allow for any other information to be disclosed nordoesitallowfor any form of communication to take place. If you want your physician to receive additional information from your confidential records, a release of information for that purpose can be provided to you. To the party receiving the information: This information has beendisclosed to you from records whose confidentially is protected by federal law. Federal regulations prohibit you from making further disclosure of this information.
This authorization can be terminated at any time in writing. This authorization is valid for the duration of involvement, up to one year.