I have chosen to receive services through NATIVE HEALTH’s Behavioral Health Department. I have made this choice by my own free will and voluntarily sign this Informed Consent Form. I understand that I have the right to refuse any recommended treatment, withdraw consent to treatment and end services at any time if I decide to do so, and be advised of the consequences of my refusal or withdrawal.
I understand the type of treatment services provided by the Behavioral Health Department at NATIVE HEALTH and understand that I can ask questions any time I am unclear about my services. I understand that I have the right to participate in treatment decisions and in the development and periodic review and revision of my treatment plan. My treatment plan will include the types and frequency of services to be provided. My signature on the treatment plan will indicate my agreement with the proposed type(s) and frequency of services, as detailed on the treatment plan. My signature on the treatment plan will also serve as an acknowledgement that the purpose, type, risks, benefits, and alternatives to the agreed upon treatment types have been explained to and understood by me.
I understand that there are no guarantees that my participation in services will make me feel better. Services involve cooperation between my service provider and/or case manager and me. Therefore, I will work with them in a cooperative way in order to deal with the difficulties that brought me to request or receive services.
I understand that during service sessions, things may be talked about which might be upsetting, and that talking about such things may be necessary in order to help me with my difficulties and move me towards accomplishing my treatment goals.
I understand that some services may be provided by a Behavioral Health Technician or unlicensed professional who may be working towards graduate degrees in Psychology, Social Work, Marriage and Family Therapy, Nursing and/or Psychiatry and/or licensure under the direction of supervising clinical staff.
I have had explained to me and I understand that the information or records collected about me will be confidential according to federal and state laws concerning confidentiality of behavioral health records and information. I understand that my health information, including my behavioral health information, may be used or disclosed by NATIVE HEALTH in accordance with its Notice of Privacy Practices (NPP). I have the right to access my behavioral health records as described in the NPP. I understand that my right of access does not include access to psychotherapy notes.
I understand that state and local laws require that my service provider or any NATIVE HEALTH staff member report all cases of physical or sexual abuse or neglect of minors, and any abuse, neglect or exploitation of vulnerable adults, including the elderly or incapacitated persons.
I understand that state and local laws require that my service provider or any NATIVE HEALTH staff member report all cases involving a danger to oneself or to other persons.
I understand that relevant and necessary information concerning my case may be reviewed by staff and/or other authorized persons for quality assurance purposes and may also be discussed within clinical supervision and possibly with other service providers at case staffing and peer review meetings. These meetings are required for each patient we serve, to increase the likelihood that the appropriate treatment goals are selected. It also assures that the most effective methods are used to achieve these goals. Those in attendance at case staffing, peer review, and other quality assurance reviews are required to maintain the confidentiality of the information they are exposed to, according to federal, state, and local laws regarding the confidentiality of behavioral health records.
If you need to contact a Clinical Supervisor regarding matters related to your treatment, you may contact:
Jordan Canady, LMFT at 602-279-5262, ext. 12019 during business hours.
I understand that attendance at my scheduled sessions is important to get the full benefit of working towards my treatment plan goals. If I am unable to keep an appointment, I will notify NATIVE HEALTH as soon as possible, so that my appointment time can be available for other patients. Three missed appointments may result in a standby appointment status and may lead to a dismissal from our clinic, unless under special circumstances (ie. health crisis, epidemic, global pandemic, etc.). If a behavioral health appointment is missed without notification from me to the clinic, I understand that NATIVE HEALTH staff are required to attempt to reach me by phone, before sending a letter to my home, regarding the lack of contact. If there is still no response to the outreach attempts, I understand that NATIVE HEALTH staff may attempt to reach my identified emergency contact, for service re-engagement. To avoid such a protocol from going into effect, it is important that I inform my provider any time I am unable to attend a scheduled appointment, or any time I wish to end my services. Unless otherwise informed, I am always welcome to return to NATIVE HEALTH for services in the future, with a new behavioral health intake completed.
I understand that I may be contacted by NATIVE HEALTH after I finish services, in order to determine how the services worked out (whether it helped me with the difficulties which caused me to seek services).
I have read and/or had explained to me the basic rights of people who are involved in services at this agency. I have been given the opportunity to sign my consent to these rights and offered a copy of the Native Health Patient Rights and Responsibilities and Notice of Nondiscrimination.
Information has also been explained to me about the Behavioral Health Department’s grievance policy and procedures, of which I have an understanding as well as my right to file a grievance, should I choose to do so. I also understand that if I have a grievance with NATIVE HEALTH’s Behavioral Health Department or one of its staff, I may contact the Division Director at: 602-279-5262 ext. 12019 to file a grievance, without any retribution or discrimination towards me or any effect upon service delivery.
I have read and/or had explained to me in a manner I understand this Informed Consent. I understand that I may request copies of this and any other registration/intake forms that I have completed. By signing below, I am authorizing and consenting to all care and treatment provided by NATIVE HEALTH and its affiliated health care providers, which may include students, residents, volunteers and other trainees. Through this consent, I am authorizing all Behavioral Health services. I understand that I may refuse services from a student intern, resident, or trainee.
(602) 279-5262