Treatment Consent for Psychiatric Services

Consent to Receive Services:

I am requesting services from Comprehensive Care, LLC. The information which I have provided as a condition of my request is true and complete to the best of my knowledge. I apply for and consent to such psychiatric, psychological, consultation, counseling and/or other therapeutic services as may be recommended by the professional staff. I understand the clinical staff may discuss the services being provided to me, and that I may request the names of those involved. I further understand that my failure to comply with therapeutic recommendations of the professional staff may result in my being discharged.

I understand that I have the freedom of choice to receive services in a setting that is integrated in and supports full access to the greater community; and is a setting that facilitates individual choice regarding services and supports, and who provides them.

I understand that State and Federal laws and regulations prohibit any entity receiving confidential information from redistributing the information to any other entity without the specific written consent of the person to whom it pertains or as otherwise permitted by law and regulations.

Court Order Policy:

Written information/materials regarding the individual receiving services are subject to Court Order. Should a court order all, or any portion of, the case records of the individual receiving services, this service provider will submit them to the court.

Release of Information without Consent:

I understand that confidential information may be released without my consent when necessary for continued services; when release is necessary for aftercare purposes, the determination of eligibility for benefits, compliance with statutory reporting requirements, is unable to provide for his/her own physical safety, including but not limited to a medical emergency, or other lawful purpose; if you communicate to the treating physician, psychologist, master social worker or licensed professional counselor an actual threat of physical violence against a clearly identified or reasonably identifiable potential victim or victims; in compliance with reporting requirements under state law of incidents of suspected child abuse or neglect, or by court order.

Rights of Individuals Receiving Services:

1.       My options within the program and of other services available

2.      The program's rules and regulations

3.      The responsibility of the program to refer me to another agency if this program becomes unable to serve me or meet my needs

4.      My right to refuse treatment and withdraw from this program at any time

5.      My right not to be subjected to corporal punishment or unethical treatment which includes my right to be free from any forms of abuse, neglect, exploitation or harassment and my right to be free from restraints of any form that are not medically necessary or are used as a means of coercion: discipline, convenience or retaliation by staff

6.      My right to voice my opinions, recommendations and to file a written grievance which will result in program review and response without retribution

7.      My right to be informed of and provided a copy of the local procedure for filing a grievance at the local level or with the DMH Office of Consumer Support

8.      My right to privacy and confidentiality in respect to facility visitors in day programs, residential treatment programs, and community living programs as much as physically possible

9.      My right regarding the program's nondiscrimination policies related to HIV infection and AIDS

10.   My right to be treated with consideration, respect, and full recognition of my dignity and individual worth 

11.   My right to have reasonable access to the clergy and advocates and have access to legal counsel at all times

12.   My right to review my records, except when restricted by law

13.   My right to fully participate in and receive a copy of my Individual Service Plan/Plan of Services and Supports or Activity Plan

This includes: l ) having the right to make decisions regarding my care, being involved in my care planning and treatment and being able to request or refuse treatment; 2) having access to information in my case records within a reasonable time frame (5 days) or having the reason for not having access communicated to me; and 3) having the right to be informed about any hazardous side effects of medication prescribed by staff medical personnel

14.   My right to retain all Constitutional rights, except when restricted by due process and resulting court order

15.   My right to have a family member or representative of my choice notified should I be admitted 'to a hospital

16.   My right to receive care in a safe setting

17.   My right to confidentiality regarding my personal information involving receiving services as well as the compilation, storage, and dissemination of my individual case records in accordance with standards outlined by the Department of Mental Health and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), if applicable

Additionally, rights for individuals in supervised and residential treatment arrangement

18.   My right to be provided a means of communicating with persons outside the program

19.   My right to have visitation by close relatives and/or significant others during reasonable hours unless clinically contraindicated and documented in my case record

20.   My right to be provided with safe storage, accessibility and accountability of my funds

21.   My right to be permitted to send/receive mail without hindrance unless clinically contraindicated and documented in my case record, and

22.   My right to be permitted to conduct private telephone conversations with family and friends, unless clinically contraindicated and documented in my case record

Individual Grievance Procedure:

Comprehensive Care, LLC is dedicated to the provision of quality mental health services. No person shall, on grounds of race, color, or national origin, be denied benefits or be subjected to discrimination under any programs or activities sponsored by this agency. No person shall be handled unfairly or treated disrespectfully by a Comprehensive Care, LLC employee.

If, for any reason, you feel that you have not received proper treatment or service, you have the right to file a formal grievance.

Consent to Contact:

I authorize Comprehensive Care, LLC to contact me by text message, phone call, and email as needed with messages, reminders, etc.

Insurance Authorization:

I authorize any medical information necessary to process my Medicare, Medicaid and/or other third party insurance claims. I also request payment of government benefits to Comprehensive Care, LLC. I authorize payment of medical benefits to Comprehensive Care, LLC for services rendered.