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Alpine County Behavioral Health Services Informed Consent In order to provide you or your child outpatient behaviorall health services it is necessary to obtain your INFORMED CONSENT. Informed consent means first, that you fully understand: 1. The nature of treatment being offered, including possible risks and alternatives 2. The guidelines, rules and procedures of providing treatment that apply to you and us 3. The financial responsibility you have for services 4. Limits of confidentiality and rights of clients and, secondly, that you freely choose to participate with behavioral health services. 1. Limits of Confidentiality: All communication with you regarding your treatment is confidential. We can share confidential information if you authorize us to do so in writing or if ordered by the court. The law requires us to report any incident of child or elder abuse including physical abuse, sexual abuse and neglect. We also have a duty to take reasonable action to prevent someone from harming themselves or others, warn an intended victim and notify the police of threats to harm another. I hereby acknowledge that I have been provided with a copy of Alpine County’s Notice of Privacy Practices on this date. 2. Title, Training, and Experience: Staff who provide services will share with you their title, training and experience. Please don’t hesitate to ask additional questions about the qualifications of staff. 3. Record Keeping System: All client names are entered into a computer-based Information System that identifies the program(s) that is/are providing services to the client. This information is available without client authorization to any workforce member of the Department’s directly-operated or contract service agency system. Information from a client’s clinical record relative to service delivery needs may be shared within this agency and within the Alpine County behavioral health system (directly-operated and contract agencies) without obtaining the authorization of the client. 4. Type, Length and Risk of Services Provided: In your intake interview, staff will share with you: 1) the type and amount of behavioral health services that have been authorized, 2) any risks involved in participating in these services and 3) any alternatives to the services we offer. Your signature below indicates that you understand the nature of services, risks involved, and alternatives to treatment and that you wish to obtain behavioral health services from us. 5. Fees and Billing Procedure: You will have a financial interview which explains our billing procedure and your financial responsibility. Please ask staff any questions you have about fees. 6. The Right of the Client: Clients have a number of rights associated with receiving mental health services, including the right to identify goals that will be the focus of treatment, to ask questions about treatment procedures, to propose changes in treatment and the right not to proceed with treatment or to voluntarily withdraw from treatment. 7. The Responsibility of the Client: Be honest and open with staff when sharing information about yourself or child, attend scheduled appointments on time, be prepared to participate, be free from alcohol or street drugs, call 48 hours in advance to cancel an appointment, don’t engage in threatening or dangerous behavior, pay your bill and provide insurance information let us know of any concerns you have about your services. 8. Emergency Access to Services: Alpine County Behavioral Health provides a Crisis line that is available to you 24 hours a day, 7 days a week. 9. Brochures: Written information has been provided to you regarding the services available under the Behavioral Health Plan and procedures for filing a grievance. My signature below indicates that I fully understand all the information about services listed above, that I am aware of the risks, responsibilities and alternatives to mental health services and that I freely choose to participate in treatment with staff of Alpine County Behavioral Health. Client/Guardian Signature Please Print Name Legal Relationship Date