Informed Consent for Counseling Services
CONSENT TO TREATMENT
I, {Name (First):36.3} {Name (Last):36.6} give consent to take part in the services provided by Atlanta Mission. I understand that developing a Personalized Service Plan with the treatment team and regularly reviewing our work toward the outcome goals are in my best interest. I agree to play an active role in this process. I am aware that I may stop treatment at any time.Consent to Treatment (Required)* I consent to the above statement (Required)*
Read over each section and check the box by each section indicating your agreement.
ELIGIBILITY (Required)* ELIGIBILITY (Required)*
I understand that eligibility for services is contingent remaining compliant with the Make Progress guidelines.
PROVISION OF SERVICES (Required)* PROVISION OF SERVICES (Required)*
I understand that Atlanta Mission offers a variety of clinical services to clients and their families, including: intake assessment, short-term individual counseling, crisis intervention, group counseling, case management, and how best to serve my needs. I further understand that appropriate referrals will be provided to me if it is determined that I would be best serviced by another community resource.
NATURE OF COUNSELING (Required)* NATURE OF COUNSELING (Required)*
I understand that there may be both risks and benefits associated with participation in counseling. Counseling may improve my ability to relate with others, provide a clearer understanding of myself, my values, and my goals, and an ability to deal with everyday stress. I understand that counseling may also lead to unanticipated feelings and change, which might have an unexpected impact on me and my relationships.
CONFIDENTIALITY (Required)* CONFIDENTIALITY (Required)*
I understand that Atlanta Mission treatment team members maintain confidentiality in accordance with the ethical guidelines and legal requirements of their profession. Effective counseling sometimes requires that staff members share confidential information with other staff members. This collaboration may also include trainees, whose work is supervised at Atlanta Mission by licensed clinical staff. Records are kept for the period required by ethical and legal guidelines; that period is presently 7 years or until the minor turns 1; whichever is longer.
I understand that the Atlanta Mission utilizes Salesforce, a web-based client management software to store client information, including service plans and clinical notes.
I understand that no records or information about me will be released from Atlanta Mission without my permissions, except under certain circumstances.
1. If I present a serious danger to myself or another person.
2. If I was abused (physically or sexually) or neglected as a child, and if other minor children are currently at risk of being abused or neglected by the person(s) who abused me.
3. If I am under 18 years of age and disclose abuse or neglect to my counselor.
4. If Atlanta Mission learns that an elderly person or a dependent adult is being abused or neglected.
5. If I have physically or sexually abused a minor child and that child or other minor children are at risk of ongoing abuse.
6. If a valid subpoena is issued for my records or my records are otherwise subject to a court order or other legal process requiring disclosure.
STAFF (Required)* STAFF (Required)*
Atlanta Mission employs professional and high-quality staff to provide services to our clients. Staff have numerous years of experience in providing services in various treatment settings. Atlanta Mission’s staff consists of licensed Master’s Level Clinicians, case managers, paraprofessionals, and professionals-in-training. All professionals-in-training are supervised by Kimberly Livsey, MS, LPC, Clinical Director and may conduct assessments, individual family, and group therapy.
NOTICE OF PRIVACY PRACTICES (Required)* NOTICE OF PRIVACY PRACTICES (Required)*
I have received, read, AND understood the NOTICE OF PRIVACY PRACTICES. It describes how medical information about me may be used and disclosed and how I can get access to this information. I understand that individually identifiable information about my past, present, or future health or condition, the provision of healthcare to me, or payment for healthcare is considered Protected Health Information (PHI). Atlanta Mission is required to extend certain protections to my PHI. The Notice of Privacy Practices gives me notice about privacy practices that explains how, when, and why they may use or disclose my PHI.
NOTICE OF PRIVACY PRACTICES (Required)* REASON FOR DENIAL OF SERVICES (Required)*
1. Unwillingness to participate/engage in services.
2. Receiving multiple infractions for violating Community Living Guidelines (4 strikes).
3. Violating guidelines that result in an automatic discharge (ex: leaving property unauthorized, physical violence, violating someone else’s safety, etc. as outlined in Community Living Guidelines.)
AUTHORIZATION TO TRANSPORT (Required)* AUTHORIZATION TO TRANSPORT (Required)*
I, {Name (First):36.3} {Name (Last):36.6} give consent and permission for Atlanta Mission’s treatment team members to provide transportation for myself, {Name (First):36.3} {Name (Last):36.6} , as needed to and from any planned activities. I understand that authorization will remain in effect for the duration of services. I acknowledge that transportation is voluntary and during transportation, the treatment team member will not knowingly or intentionally place me or my minor child in danger and will seek emergency assistance in unforeseen circumstances occur that require any such public emergency official services. I understand this agreement and that I may withdraw my consent at any time by providing written notification of my withdrawal to consent to transportation by Atlanta Mission’s treatment team members. By signing the transportation agreement, clients and/or parents agree to forgo any future legal action, if injury to myself or my minor child was unpreventable by the staff driver.
CONSENT
I certify that I have read, understand, and agree to abide by the information outlined above regarding my eligibility and participation in services provided by Atlanta Mission. I hereby give my consent to authorize Atlanta Mission to evaluate, treat, and/or refer me to others as needed. I have had the opportunity to discuss any questions regarding the above information.
Revocation of Authorization
________________________________________________
Client Signature
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Date Informed Consent RevokedConsumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures
Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.
You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.
Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.
Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.
Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.
Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.
“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.
“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .
“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.
The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.
Legal Consent (Required)* Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures
I agree to the terms and conditions.
