...the under-signer, hereby attest that I have voluntarily entered into treatment, or give my consent for the minor or person under my legal guardianship mentioned above, at Serenity Counseling & Wellness Center, hereby referred as the Center. Further, I consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. The rights, risks and benefits associated with the treatment have been explained to me. I understand that the therapy may be discontinued at any by either party, the clinic encourages that this decision be discussed with the treating psychotherapist. This will help facilitate a more appropriate plan for discharge.
Recipient’s Rights: I certify that I have received the Recipient’s Right’s pamphlet and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information from the Recipient’s Rights Advisor.
Non-Voluntary Discharge from Treatment: A client may be terminated from the Center non-voluntarily, if:
A. The client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the clinic, and/or;
B. The client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment, or payment arrangements in a timely manner.
The client will be notified of the non-voluntary discharge by letter. The client may appeal this decision with the Clinic Director or request to re-apply for services at a later date.
Client Notice of Confidentiality: The confidentiality of patient records maintained by the Center is protected by Federal and/or State law and regulations. Generally, the Center may not say to a person outside the Center that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless;
A. The patient consents in writing,
B. The disclosure is allowed by a court order, or
C. The disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.
Violation of Federal and/or State law and regulations by a treatment facility or provider is a crime. Suspected violations may be reported to appropriate authorities. Federal and/or State laws and regulations do not protect any information about a crime committed by a patient either at the Center, against any person who works for the program, or about any threat to commit such a crime. Federal and/or State laws and regulations do not protect any information about suspected child (or vulnerable person) abuse or neglect, or adult abuse from being reported under Federal and/or State laws and/or regulations to appropriate authorities. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is the Center’s duty to warn any potential victim, when a significant threat of harm has been made.
In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records. Professional misconduct by a health care professional must be reported by other health care professionals, in which related client records may be released to substantiate disciplinary concerns. Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.
When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about client, not clinical information.
Client date of clinical outcomes may be used for program evaluation purposes, but individual results will not be disclosed to outside sources.
My signature below indicates that I have been given a copy of my rights regarding Consent to Treatment and Recipient’s Rights. I permit a copy of this authorization to be used in place of the original.