I hereby request and authorize Beacon Psychology Services, LLC (hereafter referred to as "Beacon Psychology") and its respective personnel to provide mental health services/treatment to my child/legal dependent (hereafter referred to as "child" I understand that mental health services/treatment may include and are not limited to assessment services including tests and procedures as well as therapeutic treatments, and that I am agreeing only to those services that Beacon Psychology is qualified to provide within the scope of the provider'(s) license, certification, and training or the scope of license, certification, and training of those provider'(s directly supervising the services received by my child or me. I understand that with this consent, I give permission for aspects of my child's private healthcare information tobe shared with Beacon Psychology, as is necessary for services to be provided. I understand that these services do not come with guarantees, that no guarantees have been given to me by Beacon Psychology, and that certain risks may be present in my child's participation in these services. I also understand that, at any time, I can terminate this consent for treatment for my child by putting such request in writing.
I understand that communications within Beacon Psychology will be confidential. I understand that there are special circumstances that will require Beacon Psychology to break that confidentiality. By law, Beacon Psychology must report actual or suspected child or elder abuse to the appropriate authorities. In addition, Beacon Psychology is legally bound to take appropriate action if my child or I threaten anyone with violence, harm, or dangerous actions. I am aware that I can ask further questions about confidentiality with any personnel.
I hereby acknowledge that I have been offered a copy of the 'Notice of Privacy Policies' and understand the information included in this document. I am aware that a copy of this notice will be given to me when I ask for a copy.