Consent To Treatment

I, the undersigned, 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 Owens Behavioral Health, LLC, hereby referred to as the Practice. 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 time by either party. The Practice 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 Rights link here and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information from my therapist.

Nonvoluntarily Discharge from Treatment: A client may be terminated from the Practice nonvoluntarily. if: (A) the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the Practice, 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 staff or request to reapply for services at a later date.

Client Notice of Confidentiality: The confidentiality of patient records maintained by the Practice is protected by federal and/or state law and regulations. Generally, the Practice may not say to a person outside the Practice that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless: (1) the patient consents in writing, (2) the disclosure is allowed by a court order, or (3) 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 law and regulations do not protect any information about a crime committed by a patient either at the Practice, against any person who works for the program, or about any threat to commit such a crime.  Federal law and regulations do not protect any information about suspected child (or vulnerable adult) abuse or neglect, or adult abuse from being reported under federal and/or state law to appropriate state or local authorities. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. In is the Practice’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 record.  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 record. When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about the client, not clinical information. My signature below indicates that I have been given a copy of my rights regarding confidentiality.  I permit a copy of this authorization to be used in place of the original.  Client data of clinical outcomes may be used for Practice evaluation purposes, but individual results will not be disclosed to outside sources.