Treatment Risks and Benefits:
Approaches that are commonly utilized by your BHM include cognitive behavioral therapy (CBT), motivational
interviewing (MI) and dialectical behavior therapy (DBT). At times, and if deemed clinically appropriate and necessary, your BHM may administer a variety of screening and assessment tools. Your signature indicates your consent to allow your BHM to administer these instruments as clinically indicated.
Treatment goals are identified and discussed with you after the initial meeting, and as a patient it is your responsibility to participate in working toward the goals set. Emotional risks involved in treatment include disclosing personal feelings, talking about life experiences which may at times be painful or upsetting, asking for help and assistance, expressing emotions such as affection, anger, fear, and sadness, receiving emotional support, and receiving positive and constructive feedback. In addition, there is the potential for therapeutic services rendered to result in no benefit to the patient.
Tele Behavioral Health
May include sessions completed via phone or video utilizing various technologies to provide services when the BHM and patient are in different locations. Systems will be in place to protect patient’s information and confidentiality. There are inherent confidentiality risks with electronic communication and potential for technology failure. The BHM will establish an emergency procedure with the patient should the need arise during a tele behavioral health visit.
Termination
When your identified goals have been attained, then you will collaborate to identify a plan through which services can be closed in a manner that is supportive and therapeutic for you. At times changes in eligibility will impact a patient’s healthcare coverage. In the event that a change in eligibility occurs, you will be notified of this change and offered the opportunity to continue services on a private pay basis until eligibility can be restored. Should you be unable to pay this fee, a referral will be made for alternative free or low-cost mental health services that may be available to you.
Appointments
It is your responsibility to ensure that sessions are kept. If you are not able to attend a pre-scheduled session, you are to contact your provider’s office at least 24 hours before your session to cancel or reschedule.
Records
All of your records will be kept in a secure location. If you would like a copy of any records, please follow the procedure of your doctor’s office to request records.
Afterhours Resources and Emergency Response
Should a life-threatening emergency develop at any time, please contact 911. For an urgent, but non-life-threatening matter that arises during normal business hours, please contact your BHM for guidance and assistance. For assistance and support on weekends and after regular business hours, please contact the Crisis Line: 800-273-8255 (National Line)
Please sign below to indicate your understanding of, and agreement with, the terms and conditions set forth in this Informed Consent document as they pertain to treatment and the risks inherent thereof.