I, the undersigned, hereby attest that I have voluntarily entered treatment, or give my consent for the minor or person under my legal guardianship mentioned above, at Best Practice Psychotherapy, LLC, hereby referred to as the Practice. Further, I consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. 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. The Practice encourages that this decision be discussed with the treating psychotherapist. This will help facilitate a more appropriate plan for discharge.
Client Rights: I certify that I have received the Recipient’s Rights pamphlet and certify that I have read and understand its content.
Nonvoluntarily Discharge from Treatment: A client may be terminated from the Practice nonvoluntarily. if: (A) the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the Practice and/or (B) the client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. The client will be notified of the nonvoluntary discharge by letter. The client may appeal this decision with the Practice Director or request to reapply for services later.
Client Notice of Confidentiality: The confidentiality of client records maintained by the Practice is protected by federal and/or state law and regulations. Generally, the Practice may not say to a person outside the Practice that a client attends the program or disclose any information identifying a client as an alcohol or drug misuser unless: (1) the client consents in writing, (2) the disclosure is allowed by a court order, or (3) the disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.
Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is the Practice’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. Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records. When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about the client, not clinical information.
My signature below indicates that I have been given a copy of my rights regarding confidentiality. Client data of clinical outcomes may be used for program evaluation purposes, but individual results will not be disclosed to outside sources.
I consent to treatment and agree to abide by the above-stated policies and agreements with Best Practice Psychotherapy, LLC
(In a case where a client is under 18 years of age, a legally responsible adult acting on his/her behalf)