WP E-Signature by Approve Me - Sign Documents Using WordPress -

INFORMED CONSENT FOR TREATMENT

Client Name: Client Date of Birth :

Options Location:

Permission to Evaluate and Treat

I authorize the staff of Options Counseling & Family Services to complete a mental health assessment and provide mental health treatment and counseling in response to my request for services. My request for mental health services at Options is voluntary. I may ask questions about my treatment at any time and I may stop my treatment at any time. I understand that the mental health assessment that I am consenting to receive is not the same as a psychological evaluation, my mental health provider is only providing evaluation for the purposes of treatment and not to meet any legal purpose.

I acknowledge that Options offers a range of services including individual therapy, family therapy, group therapy, psychiatric services including assessment and medication management, case management, consultation, skills training, and caregiver peer support. Services at Options may be office, home or community based.

I understand that all services are intended to address an identified behavioral health condition and that services are expected to assist me in making improvements to that identified behavioral health condition. I understand that the services offered to me will be based on my medical need and specific behavioral health condition. By initialing I agree that I have read and understand this section:

Children 14-17

If I am between the ages of 14-17, I understand that I have the right to start mental health treatment without consent from my parent or guardian. I understand that Oregon law requires that my parent or guardian is involved before the end of treatment unless they refuse or there is a safety reason or concern that they should not be involved. This reason will then be documented in my record.

By initialing I agree that I have read and understand this section:

Child and Family Clients:

If I am the parent or guardian of a child client, I understand that my child is the client. I also understand that I am an important part of my child’s treatment and will be participating in that process. If my own mental health concerns emerge during that process, I may be supported to seek therapy services for myself.

By initialing I agree that I have read and understand this section:

Legal Guardianship/Custody

Options adheres to Oregon law which permits all parents or legal guardians the right to inspect, consult, and authorize emergency medical and mental health care (ORS 107.154). Any adjustments to this policy including restrictions on medical decision making, allowances or restrictions for contact between a parent and minor child, court orders for counseling, and/or any other legal documentation related to the medical care of the child must be provided in writing and a copy held in the mental health record. Options will request any such records at the initiation of services. It is the parent and/or legal guardian’s responsibility to ensure that they are acting within their rights or informing the treatment team if changes occur within the course of treatment.

By initialing I agree that I have read and understand this section:

Telehealth/Telemedicine Consent

I consent to receiving services by telehealth, I authorize the staff of Options Counseling & Family Services to provide mental health services via electronic means through interactive videoconferencing equipment and/or telephone. I acknowledge that my participation in telehealth is voluntary, and I understand that I have the right to refuse or stop treatment via telehealth at any time.

To participate in telehealth services with Options staff I may be asked to download security compliant videoconferencing software onto my personal phone, tablet, or computer. If I do not have a personal phone, tablet, or computer one may be provided at no cost to me.

The risks associated with telehealth may include disruption of transmission due to technology failures, interruption and/or breaches of confidentiality by unauthorized persons. To minimize risks my provider and I will review plans to address unexpected disconnections (dropped video calls), safety planning, and the establishment of appropriate confidential locations for services to be conducted.

All Options providers will be providing telehealth services from a confidential environment. I understand that it is my responsibility to maintain privacy on my (the client) end of communication. However, services provided where the client appears to be in a non-private or public location in which the provider believes may be detrimental to the therapeutic process may be prematurely ended and rescheduled for another time. Additionally, Clients requesting services outside of Oregon may be limited to the licensing requirements of their clinician.

There will be no recording of any telehealth sessions by myself or my provider unless prior written consent is obtained in advance.

By initialing I agree that I have read and understand this section:

Outcome Measure

For the purpose of monitoring and improving services, I acknowledge that I may be asked to fill out questionnaires related to my symptoms and how I feel my treatment is progressing. Information from the questionnaires may help me and my provider monitor improvement and make adjustments in the treatment plan if necessary. I understand that my personal information is kept strictly confidential.

I understand that I may refuse to participate at any time.

By initialing I agree that I have read and understand this section:

Individual Rights

In addition to all applicable statutory and constitutional rights, every individual receiving services has the right to:

Choose from services and supports that are consistent with the assessment and service plan, culturally competent, provided in the most integrated setting in the community and under conditions that are least restrictive to the individual’s liberty, that are least intrusive to the individual, and that provide for the greatest degree of independence;
Be treated with dignity and respect;
Participate in the development of a written service plan, receive services consistent with that plan and participate in periodic review and reassessment of service and support needs, assist in the development of the plan, and receive a copy of the written service plan;
Have all services explained, including expected outcomes and possible risks;
Confidentiality and the right to consent to disclosure in accordance with ORS 107.154, 179.505, 179.507, 192.515, 192.507, 42 CFR Part 2 and 45 CFR Part 205.50;
Give informed consent in writing prior to the start of services, except in a medical emergency or as otherwise permitted by law. Minor children may give informed consent to services in the following circumstances:
1. Under age 18 and lawfully married;
2. Age 16 or older and legally emancipated by the court; or
3. Age 14 or older for outpatient services only. For purposes of informed consent, outpatient service does not include service provided in residential programs or in day or partial hospitalization programs.
Inspect their service record in accordance with ORS 179.505;
Refuse participation in experimentation;
Receive medication specific to the individual’s diagnosed clinical needs, including medications used to treat opioid dependence;
Receive prior notice of transfer, unless the circumstances necessitating transfer pose a threat to health and safety;
Be free from abuse or neglect and to report any incident of abuse or neglect without being subject to retaliation;
Have religious freedom;
Be free from seclusion and restraint;
Be informed at the start of services and periodically thereafter of the rights guaranteed by this rule;
Be informed of the policies and procedures, service agreements and fees applicable to the services provided, and to have a custodial parent, guardian, or representative assist with understanding any information presented;
Have family and guardian involvement in service planning and delivery;
Have an opportunity to make a declaration for mental health treatment, when legally an adult;
File grievances, including appealing decisions resulting from the grievance;
Exercise all rights set forth in ORS 109.610 through 109.697 if the individual is a child, as defined by these rules;
Exercise all rights set forth in ORS 426.385 if the individual is committed to the Authority; and
Exercise all rights described in this rule without any form of reprisal or punishment.
The provider shall give to the individual and, if appropriate, the guardian a document that describes the applicable individual’s rights as follows:
1. Information given to the individual shall be in written form or, upon request, in an alternative format or language appropriate to the individual’s need;
2. The rights and how to exercise them shall be explained to the individual, and if applicable the guardian; and
3. Individual rights shall be posted in writing in a common area.

By initialing I agree that I have read and understand this section:

Client Grievance Procedure

I understand that complaints may be made verbally (the front desk coordinator may direct you to the right person) or in writing. Forms are available at the front desk. I understand that I have the right to have assistance in filing a complaint.

You are encouraged to start with Step One and progress to the next step(s) as necessary until the matter is resolved:

Discuss concerns with your provider.
Discuss concerns with your provider’s supervisor.
Discuss concerns with the Behavioral Health Director.
Discuss concerns with the Senior Behavioral Health Director.
Discuss concerns with the Quality Improvement Director.
Discuss concerns with the CEO of Options.
File a written complaint with the CEO of Options.

I acknowledge that I may also make a complaint to the Coordinated Care Organization, Oregon Health Authority’s Addiction and Mental Health Division, or Disability Rights Oregon, and that information about how to make a complaint is also available in the waiting areas or from any Options employee.

An Options staff member will respond to your complaint within five business days. You may request an accelerated response if you or your child's health is at risk. Expedited complaints will be reviewed immediately (same day) and a decision to shorten the timelines of the process will be made as soon as possible. You will not be denied service or otherwise be discriminated against or experience retaliation because a complaint has been made by you or on your behalf.

To contact the County or Coordinated Care Organization where you receive treatment:

In Clackamas County

Clackamas County Behavioral Health Division

2051 Kaen Road, #367, Oregon City, OR 97045

Phone: (503) 742-5335

Fax: (503) 742-5304

In Lane County

Trillium Community Health Plan

Lane County Quality Improvement Coordinator

P.O. Box 11756, Eugene, OR 97440-3956

Phone: (541) 682-7584

PacificSource Community Solutions

Attn: Appeals and Grievances

PO Box 5729 Bend, OR 97708

Phone: (503) 210-2515 or (800) 431-4135

TTY: (800) 735-2900

Fax: (541) 322-6424

In Marion County

PacificSource Community Solutions

Attn: Appeals and Grievances

PO Box 5729 Bend, OR 97708

Phone: (503) 210-2515 or (800) 431-4135

TTY: (800) 735-2900

Fax: (541) 322-6424

In Multnomah County

Multnomah County MHASD

Quality Management Committee

421 Oak Street Suite 520, Portland, OR 97204-1620

Phone: (503) 988-5887

In Washington County

Washington County Health and Human Services

155 N. First Avenue, MS #70, Hillsboro, OR 97124

Phone: (503) 846-4554

A coordinated care organization (CCO) is a network of all types of health care providers. This may include physical health care, addictions and mental health care, and sometimes dental care providers. These providers work together in their local communities to serve people who receive their health care coverage through the Oregon Health Plan (OHP).

By initialing I agree that I have read and understand this section:

Risks & Benefits

By agreeing to receive services from Options Counseling & Family Services, I acknowledge that the risks and benefits of treatment have been discussed with me. The risks and benefits of treatment include, but are not limited to, the following:

Benefits

Determining my strengths and goals for treatment
Choosing which goals are priorities and working with my therapist in deciding how to reach those goals
Having the opportunity to become more independent
Enjoying increased satisfaction with the quality of my life
Developing a personalized plan to address safety or crisis situations
Experiencing an increase in positive responses to difficult situations
Improving my coping abilities and reducing my stress
Improving my personal relationships

Risks

Experiencing uncomfortable levels of feelings like sadness, guilt, anxiety, anger, frustration, loneliness and helplessness
Being in touch with painful emotions, sometimes for the first time, which may temporarily lead to feeling worse
Recalling or talking about unpleasant aspects of my life, which can bring up uncomfortable feelings
Personal growth sometimes requires changes that may be uncomfortable or unexpected
Significant others may notice the changes I make; my relationships with others may be affected by the changes I make
I may not achieve my desired level of improvement.

By initialing I agree that I have read and understand this section:

I understand that I have the right to refuse or stop treatment at any time. I understand that refusal or stopping treatment may have an effect on my condition, it may worsen, stay the same, or get better.

My signature indicates that I have read and understand/agree to the provided policies, which will be used while I or my family member is in treatment. I have been offered a copy of my rights, and they have been verbally explained to me. I have had the opportunity to ask questions. I give permission to Options Counseling & Family Services to provide outpatient behavioral health treatment to me or my family member.

Relationship to client : SelfParentGuardian

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

May 7, 2020 2:08 pm PST

INFORMED CONSENT FOR TREATMENT Uploaded by Adam Falk - adam.falk@options.org IP 69.1.101.108

May 7, 2020 2:18 pm PST