Consent for Treatment 101708 - Integrated Services for ...

1 Consent for Treatment Ohio Department of Mental Health (ODMH) Ohio Department of Alcohol and Drug Addiction Services (ODADAS) Consumer Name: My clinician/service provider has explained to me and/or my child /legal ward the possible benefits and risks of the proposed Treatment . He or she has also informed me of alternative types of Treatment including their possible benefits. Furthermore, my questions regarding the implications and potential consequences of refusing Treatment at this time have been answered. I realize that at any time during my Treatment at Integrated Services of Appalachian Ohio, if I have any additional questions or concerns I can ask my clinician/service provider. Therefore, I give my Consent to enter into Treatment and agree to work with my clinician/service provider to accomplish the goals on the proposed service plan.

2 I understand that the course for Treatment may change with subsequent service plans that my clinician/service provider and I will develop and which we will discuss. I also understand that I can withdraw from Treatment at any time and if I have questions concerning this, I can discuss them with my clinician/service provider. I have received the Notice of Privacy Practices and Consumer Handbook of Integrated Services of Appalachian Ohio. Initial Here I request that confidential communications be sent to an alternate address Any information necessary to obtain payment for Treatment / Services rendered will be submitted to the appropriate ADAMHS/CMH/ADAS Board and state agency(s). Consumer Signature/Legal Guardian Date Witness Signature Date I, , being a minor of 14 years of age or older, request the Services of an Integrated Services of Appalachian Ohio mental health professional, given the risks and benefits explained to me.

3 I also understand that Treatment shall not exceed thirty (30) days or six (6) sessions, whichever occurs sooner, and that the Treatment excludes the use of medication. Signature of Minor Date Witness Signature Date Integrated Services recognizes your right to refuse Treatment or withdraw from current Treatment . Integrated Services agrees to develop alternative approaches for Services , including referrals to other agencies and/or providers for needed Services . I wish to withdraw my Consent for Treatment . The implications and potential consequences of refusing or withdrawing from the proposed Treatment have been explained to me. Consumer Signature/Legal Guardian Date Witness Signature Date C:\- Integrated Services Projects\MH Forms - ISS\ Consent for Treatment