Consent to Mental Health Services

Your signature on this form confirms your consent to mental health services to be rendered to you or a person for whom you are a legal representative or are a legal guardian (Power of Attorney). The details of such mental health services have been explained to you as well as the risks and benefits of treatment, of alternative treatments, and of no treatment at all. You also understand there is NO GUARANTEE that any particular result will be achieved.

 

DO NOT SIGN THE FORM IF YOU HA VE ANY QUESTIONS THAT YOU THINK IMPORTANT TO YOUR DECISION AND CONSENT.

 

I understand and agree to mental health services that Sound Wellness Telepsychiatry is qualified to provide within:

1. The scope of the provider's license, certification, and training; or

2. The scope of the license, certification, and training of those mental health providers directly supervising the services I receive.

{Sound Wellness Telepsychiatry} Client Handbook Receipt

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•  I have had the Client's Rights and Grievance Procedure explained to me.  

• A copy of these rights and procedures was printed out as my copy.

•  I have been provided a copy of the Notice of Privacy Practices and have been notified of how my health information may be used and disclosed by Sound Wellness Telepsychiatry and how I may access and control this information. By signing below, I also consent to use and/or disclosure my health information to treat me and arrange for my mental health care, to seek and receive payment for services given me, and for the business operations of Sound Wellness Telepsychiatry and its staff.

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For office use only: If the client does not sign this acknowledgment and consent form, record here the good faith efforts made to obtain this acknowledgment and consent or reason for lack of signature.