Informed Consent & Medical Treatment Agreement

I,   First Name*   Last Name* , 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 If consent for treatment is still withdrawn or revoked, efforts will be made to ensure that the person understands the implications and consequences of not receiving treatment.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.

I,   First Name*   Last Name*   as a participant in medical treatment at On Demand Counseling, understand and voluntarily agree that:

The following information explains what I can expect while receiving treatment at On Demand Counseling. While this is an overview of all programming, treatment will always be tailored toward my individual needs.

I will keep (and be on time for) all scheduled appointments with the providers of the treatment program.

I will make sure to schedule a follow up appointment to ensure I don't run out of medication. If I am having trouble making an appointment, I will tell a member of the treatment team immediately.

We will help you to schedule regular appointments for medication refills. If we must cancel or change your appointment for any reason, we will make sure you have enough medication to last until your next appointment.

I will participate in individual counseling, groups, 12-step recovery programs, or other types of treatment resources that are recommended for my recovery.

I will keep prescribed medicine safe, secure, and out of the reach of children. If the medicine is lost or stolen, I understand it may not be replaced until my next appointment.

I will take my prescribed medication as instructed, and not deviate from said instructions without consulting with my provider or another member of the treatment team.

I will tell my provider or another member of the treatment team if I discontinue my treatment for any reason. I understand that I will need to plan for any surgeries or other medical procedures for which I may need pain medication.

I will engage in random urine drug tests and pill counts when asked. I understand that it is my responsibility to ensure the office has my updated contact information, and any missed urine drug screens will be considered positive and in violation of this agreement.

We will keep a record of your prescriptions and screen for any illicit substance use regularly so you are being monitored appropriately.

We will help in connecting you with counseling, 12-step programs, or other positive resources to support you on your recovery journey.

We will help you to set treatment goals and monitor your progress in achieving those goals.

We will issue prescriptions to be filled at the pharmacy of your choice.

We will make sure this treatment is as safe as possible. We will check regularly to make sure you are not having any negative side-effects.

I understand that I may lose my right to treatment at On Demand Counseling, if I violate any part of this agreement.