INFORMED CONSENT FOR TREATMENT
I attest that I have voluntarily entered treatment/requested services or given my consent for the minor/person under my legal guardianship mentioned above. I consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor or intern in collaboration with his/her supervisor.
I understand NAK Union Behavioral Health is a Comprehensive Behavioral Health Program and does not offer Medication Management Services Only. 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. NAK Union Behavioral Health (“NAK”) encourages that this decision be discussed with the treating therapist. This will help facilitate a more appropriate plan for discharge.
Non-Voluntary Discharge from Treatment
A client may be terminated from NAK non-voluntarily, if:
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A) The client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the clinic.
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B) The client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations or does not make payment in a timely manner.
The client will be notified of the non-voluntary discharge by letter. The client may appeal this decision with the Clinical Director or request to re-apply for services at a later date.
Client Notice of Confidentiality
The confidentiality of patient records maintained by NAK and/or State law and regulations. Generally, NAK may not say to a person outside NAK that a client attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless:
1. The client consents in writing
2. The disclosure is allowed by a court order
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 NAK 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.
It is NAK’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 records.
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.
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 program evaluation purposes, but individual results will not be disclosed to outside sources.
In signing this consent, I am stating that I understand and agree to the treatment I will receive and that the benefits and risks of this procedure have been explained to me. I understand that I may terminate or withdraw from this treatment at any time.
I consent to treatment and agree to abide by the above.
Signature
