I, * * , hereby authorize On Demand Counseling to utilize customary behavioral health treatment services in providing care.
These services will be provided by On Demand Counseling staff or consultants. I concur with the following: I have received the statement of client rights and I have accepted my initial fee agreement. I will participate in forming a plan for my own treatment as my signature on the individual service plan will affirm. Further, I understand that while counseling and other services provided by the agency offer reasonable expectation of benefit, there is no certainty of success. There may be minimal risk inherent that it is my responsibility to inform On Demand Counseling service providers of any problems or side effects that may develop in the course of my treatment so that they may be addressed.
On Demand Counseling recognizes and affirms a person's right to refuse or withdraw consent for treatment. In this event, efforts to develop alternative approaches in collaboration with the person services will be made to ensure that the person receives needed services. If consent for treatment is still withdrawn or revoked, efforts will be made to ensure that the person understands the implications and consequences of not receiving treatment.
On Demand Counseling is a mandated reporting agency. All information a client shares is strictly confidential outside of reports of child abuse, intent to self-harm, intent to harm another individual, or intent to harm a structure. Should a client report any of the above, staff is required to contact the appropriate authorities and inform them of the client's report.