Behavioral Health Services Consumer Acknowledgements and Consent to Treatment E/S

Behavioral Health Consumer Acknowledgment and Consent to Treatment

Please read and initial the following statements related to your mental health treatment: Note: for clients who are 14 years of age or older, you can consent to behavioral health treatment without a parent signature. Clients under the age of 14 require a parent to consent to behavioral health treatment.
Client Notifications - English

Notificaciones de Clientes de Tratamiento de Clientes de BH - Español
Notice of Privacy Practices - English

Aviso de prácticas de privacidad de BH - español
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
I have received the Client Notifications, which includes rights and responsibilities, benefits and risks of treatment, attendance and technology policy, and how to file a grievance. I know that I can discuss this information at any time with my provider. *
Please Initial
I know that I can discuss this information with my provider at any time.*
Please Initial
I have been given a copy of the Notice of Privacy Practices and understand that I can ask questions about how health information will be used at any time.*
Please Initial
Client notifications and Notice of Privacy Practices are on our website: https://roguecommunityhealth.org/patient-forms/*
Please initial
I understand that my RCH provider may be coordinating my care with other RCH internal providers including Primary Care, Dental, Substance Use Treatment, Community Health Workers, and/or Housing.*
Please Initial
I understand that my mental health information is confidential and that I can discuss with my provider the limits and exceptions to confidentiality at any time, as outlined in the provided Client Notifications.*
Please Initial
I will receive a professional disclosure statement from my therapist that outlines the therapist’s training, education, experience, and my rights as a client.*
Please Initial
I have the opportunity to be provided with an Advanced Directive if I choose. I understand I can put this on file at any time and that it is in effect for a period of three years or until revoked (Adults only).
Please Initial
I have the opportunity to be provided with a Declaration for Mental Health Treatment with my provider if I choose. I understand I can put this on file at any time, and that it remains in effect until revoked (Adults only).
Please Initial
I have the opportunity to register to vote and can be provided with registration materials upon request (Adults only).
Please Initial
I acknowledge receipt of all of the above listed documents and information. I can receive copies of all of these forms upon request at any time in the future. I hereby consent to participate in my treatment and the planning of my services with my therapist.
Print Client Name (Legal Guardian if under 14) *

First NameLast Name
Relationship to the Client*
Client Signature (Legal Guardian if under 14) *

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Date*

MonthDayYear
Date
You have the right to revoke this consent at any time, by requesting in writing and emailing the Senior Director of Quality and Compliance at compliance@roguech.org. Unless revoked earlier or otherwise indicated (client discharges from treatment), this consent will expire one year from the date of signature. Behavioral health services provided by Rogue Community Health are offered on a fee-for-service basis. Rogue Community Health accepts a number of health insurance plans, and a sliding fee schedule is available, which is based on income. Please contact the Billing Department if you have questions/concerns about your bill: 541-618-4414.
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Behavioral Health Consumer Acknowledgment and Consent to Treatment