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Consent for Services and Authorization for Electronic Communication

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Consent for Services and Electronic Communication

Legal Name: Date of Birth:

CONSENT FOR SERVICES

Entry & Assessment

As part of my request for services with Center for Family Development (CFD), I authorize clinical staff to complete an assessment and provide services and supports.
My request for services from CFD is voluntary and I may discontinue services at any time.
I may ask questions at any time.

Services Offered

Center for Family Development offers individual and family therapy and additional services such as group therapy, skills training, case management, and medication management.
All services are intended to address an identified mental health and/or substance use disorder condition and are expected to assist me in making improvements to that identified condition.
Additional services will be offered to me based on my clinical need and specific mental health and/or substance use disorder condition and the availability of the services.

Treatment for Adolescents Age 14 and Older

I have the right to access mental health and/or substance use disorders services without consent from my parent / legal guardian (ORS 109.675).
My parent(s) / legal guardian(s) will be informed and involved before the end of services unless they refuse or there are clear clinical reasons not to inform or involve them, which will be documented in my record (ORS 109.675).
For youth involved in mental health services: My therapist may disclose relevant information about my diagnosis and treatment to my parent(s) / legal guardian(s) in certain limited circumstances provided by law and/or when my therapist determines the disclosure is clinically appropriate and will serve the best interests of my treatment (ORS 109.675). Records about my treatment cannot be disclosed to my parent(s) / legal guardian(s) without my written consent.
I understand that I will be asked to sign an authorization to release information when CFD’s treatment is in collaboration with other agencies / providers with whom exchange of information is necessary. I also understand that, if I choose to not sign this authorization, I may become ineligible for requested services.
Information disclosed to the adolescent’s therapist by the parent / guardian is not confidential or privileged and may be shared with the adolescent and/or service providers / collaborating agencies involved in the adolescent’s care.
For youth involved in substance use recovery services: Information and records about my treatment cannot be disclosed without my written authorization, including to my parent(s) / legal guardian(s).

Treatment for Minors Age 13 and Younger

Unless otherwise ordered by the court, biological parent(s), adoptive parent(s), and legal guardian(s) have the legal right to obtain records about their child’s mental health services, even if the parent(s) are not involved in services. Records may include individual and family therapy session notes.

Service Planning

I will be involved in the creation of my Service Plan and will continue to be involved in changes made throughout the duration of services with CFD.

Risks & Benefits

There may be periods during therapy that may result in emotional discomfort, changes in relationships and temporary worsening of symptoms. The goal and intended benefit of services and supports is the resolution of the presenting problem.

Supervision

My therapist is supervised by a clinical supervisor. My therapist may discuss my needs in an individual or group supervision setting to get help with how to best serve me.
My therapist’s supervision may happen via audiovisual technology. I consent to having my information discussed electronically.
My therapist, their supervisor, and any therapists in group supervision will keep my information confidential.
I may access my therapist's immediate supervisor upon my request should I experience concerns or wish to express a grievance.

Telehealth

CFD offers the option to receive services via telehealth using audiovisual technology or telephone. I have a choice to receive services in person or via telehealth.
My therapist and I will identify the ways for me to receive services which best meet my needs. My therapist will consider my choice and readiness to access and participate in telehealth services and will accommodate my needs as best as possible.
I consent to receiving services by telehealth as needed and as best meets my needs. My participation in telehealth is voluntary, and I have the right to discontinue services via telehealth at any time.
To participate in telehealth services, 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, I may access telehealth on a computer in a CFD office.
The risks associated with telehealth include disruption of transmission due to technology failures, interruption by someone entering my environment, and disruption of my privacy and confidentiality. To minimize risks, my therapist and I will make plans for having sessions in an appropriately confidential location, and what to do when there is an unexpected disconnection (dropped video calls) or a risky situation.
I will follow the guidelines for telehealth services:
- Be in Oregon.
- Be in a location with as few distractions as possible.
- Dress appropriately for the appointment.
- Inform my therapist when someone else is present.
All CFD clinicians provide telehealth services in a confidential environment. It is my responsibility to maintain privacy in my environment. If my environment appears to be in a non-private or public location and my therapist believes having the session may be harmful to me or to the therapy process, the session may be ended and rescheduled for another time.
I will not record telehealth sessions. My therapist will not record telehealth sessions without my prior written consent.

Therapeutic Privilege

I am the holder of privilege within the therapeutic setting. Information that is discussed during services is confidential and no information about my case can be released to anyone outside CFD without written authorization from me, except as stated below.

Mandatory Reporting

If, during services, I reveal to my therapist past or threatened abuse of a person who is in a protected category, whether that person is myself or another individual, my therapist must disclose and report such information as required by Oregon law. Individuals in the protected categories are children, elderly persons, developmentally disabled persons, and persons receiving mental health services covered by Oregon Health Plan or other public funding.
If I threaten to harm myself or others, CFD is required to intervene, which may include a report to the appropriate agency and/or authority.
In the event of threatened harm to any individual, my therapist may warn the intended victim(s) by the most efficient means available.

Release of Information

CFD may communicate with other physical and behavioral health providers involved in my care. This communication may include the sharing of physical and mental health charts. The purpose of this communication is to provide me with quality, integrated healthcare and to ensure all of my health needs are being addressed by those involved in my care.
In cases of medical emergency, CFD may access emergency medical treatment on my behalf. Information may be released to the attending emergency workers but will be limited to only information that is necessary to resolve the situation. Any information shared will be documented in my record.
In cases of psychiatric hospitalization, information about mental health status prior to hospitalization and information judged to be helpful in service conclusion planning may be released. Any information shared will be documented in my record.
If a child abuse investigation is being conducted, CFD is required under Oregon law to permit the investigating agency to inspect and copy records of the child involved in the investigation without the consent of the child or the parent/guardian of the child.
If I have concerns about my information being released, I may submit a “Request for Restriction on Use/Disclosure of Clinical Information.”

Legal Proceedings and Release of Records

If I am involved in or anticipate being involved in legal or court proceedings, I will notify my therapist as soon as possible to help them understand how, if at all, their involvement in these proceedings might affect our work together.
CFD does not provide custody evaluations or make recommendations for custody or visitation. CFD staff and therapists will not voluntarily testify in court related to recommendations for custody or visitation.
CFD does not provide family reunification services. If I am court-ordered to participate in family reunification services, I will discuss with my therapist, who may refer me to an agency that provides these services.
If information regarding my therapy becomes an issue in a court proceeding, the Judge may decide to order my confidential information be disclosed.
My therapist or other CFD staff will not volunteer confidential information within a court proceeding without my written permission.
Should a Judge order a disclosure of information regarding my therapy services, CFD staff will obey such an order.
If client records are requested for a professional licensing or credentialing board investigation, HIPAA regulation 45 CFR §164.512(d) and Substance Abuse Confidentiality Regulations 42 CFR Part 2 allow the release without a client’s consent.

Access to Records

I have the right to view and request copies of my record by written request, unless CFD determines access to my records would likely be harmful to my well-being, in which case a copy may be denied.
If I request copies of my record, I may be asked to pay for copy costs and staff time. I will not be denied access to my record because of inability to pay.

Psychological Evaluation

An assessment and services and supports are not a substitute for a psychological evaluation. CFD conducts psychological evaluations in limited circumstances.
My therapist is available to discuss the difference between an assessment, a psychological evaluation and services and supports.

Third Party Payer

If I am covered by a third-party payer, I authorize billing to my health plan and payment of benefits directly to CFD.
If I am covered by Oregon Health Plan, I am not required to pay for services provided to me.
I will inform CFD of any changes in my coverage as soon as possible. If I am covered by a payer for which coverage ends for any reason, I may be responsible for the full cost of treatment.
My information may be reviewed by my health plan, including the Oregon Health Authority or the local coordinated care organization, for funding authorization of services, quality improvement, utilization management and site review purposes.

Information Provided

I received a copy of the following information at intake: Consent for Services, Statement of Individual Rights, Notice of Privacy Practices, Grievance Procedure, Voter Registration Information, Tobacco Cessation Information, CFD Program-Specific Information, No Show/Late Show Policies, Declaration for Mental Health Treatment, and Advance Directive.

Planned Health Care Decisions (for adults, or minors who are emancipated or married)

Declaration for Mental Health Treatment

A Declaration for Mental Health Treatment allows you to let health care professionals know your preferences regarding mental health care treatment if you are ever unable to make these decisions for yourself.

The following statement is true for me:

I have already completed a Declaration for Mental Health Treatment.

I would like to complete a Declaration for Mental Health Treatment. I can request a hard copy of this document, and I can find it on CFD’s website.

I would like to get more information about the Declaration for Mental Health Treatment during the assessment.

I do not want to complete a Declaration for Mental Health Treatment at this time.

Advance Directive

The Advance Directive lets health care professionals know your preferences regarding life-sustaining help if you are near death and are unable to make these decisions for yourself. It also allows you to name a person with whom you have discussed your wishes to advocate for your choices.

The following is true for me:

I have already completed an Advance Directive.

I would like to complete an Advance Directive. I can talk to my primary care provider or call Oregon Health Decisions at 1-800-422-4805.

I would like to get more information about the Advance Directive during the assessment.

I do not want to complete an Advance Directive at this time.

Scheduling and Cancellations

I agree to keep scheduled appointments with my therapist.
I will provide at least 24 hours advance notice if I need to cancel an appointment.
I understand if I miss multiple appointments, services may discontinue.

CFD provides services to all individuals who are eligible regardless of race, ethnicity, gender, gender identity, gender expression, sexual orientation, religion, creed, national origin, age (except when program eligibility is restricted to children, adults, or older adults), familial status, marital status, source of income, and disability.

CONSENT FOR ELECTRONIC COMMUNICATION: EMAIL AND TEXT

Electronic Communication

Electronic communication means using Web sites, mobile phones, email, text messaging, online social networking, video, or other electronic methods and technology to send and receive messages, or to post information so that it can be retrieved by others or used later.

CFD offers the opportunity to communicate by electronic means using email and text messaging.

Risks of Using Electronic Communication

Electronic communications have possible risks that should be considered before using to communicate. If I am worried about any information being seen by other people, or if my question or issue is urgent, I will call CFD staff instead of communicating by electronic means.

I understand the following risks apply when communicating by electronic means including, but not limited to, the following:

Electronic communication can be forwarded to other people, saved on electronic devices, or printed out on paper for storage.
Electronic communication can be sent to the wrong person by accident.
Email or text messages can be used as evidence in court.

Use of Electronic Communication

CFD uses reasonable means to protect the security and confidentiality of email and text message information sent and received. However, because of the risks outlined above, CFD cannot guarantee the security and confidentiality (privacy) of electronic communications and will not be liable for my improper use and/or disclosure of confidential information (including Protected Health Information that is the subject of the federal Health Insurance Portability and Accountability Act of 1996).

I agree to and request the following regarding the use of electronic communication with CFD:

I will receive electronic communications from program staff at the contact information I provide.
Text messages may be used for scheduling purposes, appointment confirmation, resource information, and administrative purposes only.
Email and/or text message communication between me and CFD may be made part of my electronic health record. CFD staff who are authorized to view my electronic health record will also have access to these communications.
CFD may forward electronic communications to other CFD staff as necessary for diagnosis, treatment, reimbursement, and other operations. CFD will not, however, forward email or text messages to parties outside of CFD who are not involved in my care, without my prior written consent, except as authorized or required by law.
If I send an email or text message that requests a response from a specific staff person and I have not received a response within two (2) business days, it is my responsibility to call CFD to discuss the issue by phone.
I understand that clinical services cannot be provided over email or text messaging, and I will not use electronic communication as a form of therapy.
I will not forward links, forwards, or spam texts or emails to CFD, which may introduce viruses into electronic systems.
Emails from CFD will be encrypted (secure) and will require that I establish a password to view the information. I can request that emails be sent unencrypted (unsecure), and my acknowledgement of the risks will be documented.
I am responsible for my own actions related to the use of my devices, including paying for any charges incurred by my wireless plan, safeguarding passwords, and keeping electronic communication confidential.
I will immediately inform CFD of changes in my email address or text messaging number. Failure to do so may result in information being sent to the previously used number or address.

I authorize electronic communications by:

Text message to cell phone number

If you selected "Email":

I agree to receive encrypted emails. I understand that I need to create a username and password to access encrypted emails.

I prefer to receive unsecure emails. I understand that unsecure emails are not protected and have the potential to be accessed more easily by someone else. I accept the potential risks.

I would like to receive appointment confirmations by (choose one):

Telephone call

Text message

I may withdraw consent for electronic communication by informing CFD in writing.

My signature affirms that I have read and understand the Consent for Services and Authorization for Electronic Communication information and have had the opportunity to ask questions.

This document is being signed by: ClientPersonal representative, see below

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relation to client:

Definition of Personal Representative:

For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.

For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.

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Your legal name

Your email address

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April 3, 2025 11:32 am PDT

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April 3, 2025 11:58 am PDT

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April 21, 2025 8:30 am PDT

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