Download for your records the Consumer Handbook in English or Spanish.

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Combine Consent to Treatment
Consent 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.
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Section I – Consumer Handbook

Consent 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)

Section II – Consumer Handbook

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

Section III – Emergencies After Hours

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

Section IV – Coordination of Care

Disclose of all insurance coverage.
I understand that I must disclose all insurance coverage. if failure to disclose results is 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 (1) year from date of signing.

Section VI – Signatures

Client/Parent/Guardian Signatures
Print Full Name
Clear Signature
Date / Time