INFORMED CONSENT

Dear client:

Before obtaining any medical or counseling care it is important to gain sufficient knowledge regarding the types of treatment available, any risks, and potential benefits, this process of information gathering is known as receiving “informed consent.”

As your counselor, it is my job to discuss with you the methods of therapy and any risks. At this time I am proposing that you engage in (group therapy, individual therapy, couples’ counseling, etc.) Although many people experience no adverse reactions to counseling you need to be aware that counseling forces some persons to experience unwanted feelings such as sadness, guilt, anger and anxiousness. In addition, the counseling process often results in the life changes for the client. You may handle relationships differently than you have in the past, you may choose to change your job, you may choose to alter your lifestyle, you may make a number of alterations.

Although I will not make these decisions for you, I will be available to assist you in making alterations and understanding their impact on you and others. I will always keep you informed of any changes in therapy I propose and any risks I foresee. In addition, I may also suggest alternatives to therapy so that you can make well-reasoned decisions about your treatment.

APPOINTMENTS:

Our agency works on appointment basis. In order for your time to be reserved, it is necessary that you make appointments well in advance. Each appointment is for a “clinical hour.” A clinical hour is 50 minutes. During that time, I will take no phone calls and you will have my undivided attention. If you need to cancel, please do so at least 24 hours in advance.

TERMNINATIOIN SERVICES:

It is your right to terminate our counseling relationship at any time. I would appreciate a one week notice so that we might meet to discuss the termination and your future plans. At any time I can assist you in locating another counselor and you can authorize your records to be transferred, if necessary.

CONFIDENTIALITY:

With few exceptions, our conversations are confidential. State law, federal regulations and my code of ethics specifically guarantee this confidentiality. There are some situations, however, in which confidentiality cannot be guaranteed. They fall within the following categories:

a) I must notify appropriate person(s) if I believe that a client may harm another individual.

b) I must report child abuse, or the abuse, neglect, or the exploitation of the elderly.

c) I must respond to a subpoena accompanied by a court order.

d) I will have to respond to any situations in which I believe that the client may harm himself/herself.

If you have any further questions about office procedure, therapy options or other issues, please ask at any time. I look forward to working with you and anticipate that our counseling relationship will be mutually beneficial.

YOUR RIGHTS AS A CLIENT

Please be aware that as a client, the Urban Inter-Tribal Center of Texas wishes to insure that you are aware of your rights and that these rights be observed and protected. These include:

1) You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your personal needs.

2) You have the right to be free from abuse, neglect, and exploitation.

3) You have the right to be treated with dignity and respect.

4) You have the right to appropriate treatment in the least restrictive setting available that meets your needs.

5) You have the right to be told about the program’s rules and regulations before you are admitted.

6) You have the right to be told before admission; (a) the condition to be treated; (b) the proposed treatment; (c) the risks, benefits, and side effects of all proposed treatment and medication; (d) the probable health and mental health consequences of refusing treatment, and (e) other treatments that are available and which ones, if any, might be appropriate for you.

7) You have the right to accept or refuse treatment after receiving this explanation;

8) If you agree to treatment or medication, you have the right to change your mind at any time (unless specifically restricted by law);

9) You have the right to a treatment plan designed to meet your needs, and you have the right to take part in developing that plan.

10) You have the right to meet with staff to review and update the plan on a regular basis.

11) You have the right to refuse to take part in research without affecting your regular care.

12) You have the right to not receive unnecessary or excessive medication;

13) You have the right not to be restrained or placed n a locked room by yourself unless you are a danger to yourself or others.

14) You have the right to have information about you kept private and to be told about the times when the information can be released without your permission.

15) You have the right to be told in advance of all estimated charges and any limitations on the length of services that the facility is aware of.

16) You have the right to receive an explanation of your treatment or your rights if you have questions while you are in treatment.

17) You have the right to make a complaint and receive a fair response from the facility within a reasonable amount of time.

18) You have the right to complain directly to the Texas Department of State Health Services at any reasonable time.

19) You have the right to get a copy of these rights before you are admitted, including the address and phone number of the Texas Department of State Health Services.

20) You have the right to have your rights explained to you in simple terms, in a way you can understand, within 24 hours of being enrolled in treatment.

GRIEVANCE PROCEDURE

If you feel that any of your rights have been violated, you have the right to file a complaint or grievance- either with the management of the Urban Inter-Tribal Center of Texas or directly with the Texas Department of State Health Services. If you wish to file a grievance with the management of the Urban Inter-Tribal Center of Texas, you may do so at any time by:

1) Contact the Family Services Director at 214-941-1050 Ext. 202 and verbally notify your concern, complaint, or grievance; and/or

2) File a written complaint or notice of grievance with the Family Services by writing: Family Services Director/ “Client Confidential” Urban Inter-Tribal Center/ 1261 Record Crossing/ Dallas, TX, 75235

3) If you wish to go directly to the Chief Executive Officer of the facility to file a complaint or grievance, you may do so by contacting he/she at 214-941-1010 x202 or write to “Chief Executive Officer “Client Confidential” at the address listed in #2 above.

4) The Urban Inter-Tribal Center of Texas will review each complaint and grievance at its earliest possible opportunity and respond back in writing to the client within 3 working days of the complaint.