Combined Consent to Treatment - carrouseltherapycenter.com

Combined Consent

Section I – Consumer Handbook

I have received the Consumer Handbook. I was given time to ask questions and I understand the answers that were given to me.

YES

The Consumer Handbook has information on the following subjects:

1. Consumer Rights and Responsibilities
2. Confidentiality and Release of Requests for Information Policies
3. Notice of Private Practices
4. Grievance Procedures

Section II – Emergencies After Hours

I have been provided with a list of Recommendations for Emergencies After Hours

YES

Section III – Consent to Treatment

I understand that all information, including client assessment, treatment notes, etc. are treated with strict confidentiality and no information, either verbal or written, will be shared without the written consent of legal guardian (if client is under age of 18). I understand that individuals responsible for care through Carrousel Therapy Center will need to have access to confidential information for the purpose of assessment and treatment coordination. By law, rules of confidentiality do not hold information under the following conditions:

1. If abuse or neglect af a minor, disabled or elderly person is reported or suspected, the provider is legally required to report concern to Department of Children and Families.
2. If during services, the professionals receives information that someone’s life is in danger, the professional has a legal duty to warn the threatened individual.
3. If Company or Staff testimony is subpoenaed by Court Order, we are required to produce records or appear in Court to answer questions about the client.

I consent to treatment taking place at the following location(s)

Home

School

Office

Telehealth

Section IV – Coordination of Care

Please Select One

I consent to coordination of care with Primary Care Physician when clinically appropriate. I also authorize the Staff from Carrousel Therapy Center to release monthly updates regarding medicationn changes to the Primary Care Physician for the purpoce of continuity in care if applicable. I consent to coordination of care, witch may include sharing information verbally or in writing to psychotherapy notes related to me or my children’s treatment with all carrousel Therapy Center Staff.

I do not give consent for Carrousel Therapy Center to coordinate care with my PCP.

Section V – Financial Responsibility

I understand that I must disclose all insurance coverage. if failure to disclose results ia a denied claim, I will be financially responsible for it. Information on this page has been explained to me. I understand that i may revoke this consent at any time, except for action that has already been taken. a copy of this form shall be as valid as original for a period of one year from date of signing.

YES

Section VI – Signatures

Client/Parent/Guardian Signature

Clear

Client/Parent/Guardian Printed Full Name

Date

Therapist (Witness) Signature

Clear

Therapist (witness) Printed Full Name

Date

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