Permission to Treat

Permission for Treatment

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  • Freedom of Choice
    I understand that the choice of providers is my responsibility and right as the client or guardian.  I further understand that I have the right to contact the providers prior to selection so that I may determine the best provider.  I also understand that I may at any time choose another provider for this service by notifying my current provider.

    Informed Consent
    I understand that participation in treatment does not guarantee anticipated outcomes.  I understand that there may be unintended results of treatment affecting the client and other family/household members.  I understand that providers are legally bound to report suspected abuse of the client or of other family members.  I also understand that the providers have a duty to warn any intended victim of a threat to harm.

    Persons Participating in Home and Community Based Services
    I understand that I am giving permission to include in the client’s treatment sessions any persons present in the home, school or community at the time of service.  This includes but is not limited to me, my parents, spouses, stepparents, paramours, siblings, children, extended family, household visitors, caregivers, playmates and classmates.  I also understand that I have the right to dismiss anyone from participating in a session at any time and that I have the right to exclude anyone from the ongoing treatment process by written notice to the provider.

    Inherent Risks
    I understand that treatment may include participation in activities that include inherent risk for injury or harm and believe that the therapeutic benefits outweigh the potential risks. Activities may include but not be limited to sports activities, cooking, arts and crafts activities that may involve sharps, fire, and high heat. Activities may also include animals both domestic and farm animals including but not limited to dogs and horses. I understand that I am giving permission to participate in these activities and agree to not hold Transformations or it’s representatives liable for injury that may occur during the course of these activities.

    Telehealth Services
    I understand that telehealth services maybe recommended as part of treatment.  I have received information on the limits and process of telehealth and consent to telehealth care services.

    Privacy Practices
    I understand that Transformations adheres to the Health Information Privacy Act and I agree to these practices.  I agree that this information has been made available to me for me review.

    I understand my responsibility is to: 1) provide accurate information and report any changes in client well-being, 2) to keep all appointments and to give 24 hour notice of a need to reschedule, 3) to maintain the client’s insurance coverage and report any lapse in coverage to the service provider, 4) to contribute to a plan of treatment and to follow through with agreed upon interventions.

    I understand that I am financially responsible for any services received.  I agree to report all primary and secondary insurance coverages.  I agree to pay any co-pay, deductibles, and co-insurance agreed upon with my insurance company.   I give permission to file insurance claims on services provided with any insurance companies with which I or my child is enrolled.  I give Transformations permission to file treatment plans to request authorization for services.  I also understand that a treatment plan may include information such as diagnosis, symptoms, treatment goals, and progress reports. This release includes any dependents for which Transformations staff is also providing treatment.

    Permission is hereby given to Transformations staff and its service providers to render screening, assessment, treatment and support services to the above-named client and under the above-named conditions.

  • Click here for explanation of practices and services
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