Consent for Services


Center for Family Development

1258 High Street, Eugene, OR 97401 541-342-8437 / Fax 541-242-2999

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.

Treatment for Adolescents

  • If I am an adolescent age 14 or older, I have the right to access services without consent from my parent/guardian.
  • My parent/guardian will be involved before the end of services unless they refuse or there are clear clinical reasons not to involve them, which will be documented in my record.

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.
  • I may access my therapist’s immediate supervisor upon my request should I experience concerns or wish to express a grievance.
  • My therapist and their supervisor will keep my information confidential.

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.
  • 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.

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 does not conduct psychological evaluations.
  • 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.
  • 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 at Intake

  • 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, and Declaration for Mental Health Treatment.

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 presentation, sexual orientation, religion, creed, national origin, age, marital status, disability, or other factors prohibited by law or regulation, except when program eligibility is restricted to children, adults, or older adults, familial status, marital status, source of income, and disability.

My signature affirms that I have read and understand this form and have had the opportunity to ask questions.

This document is being signed by:

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:

Relationship 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.


Leave this empty:

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CFD Client Forms https://esign.c-f-d.org
Signature Certificate
Document name: Consent for Services
lock iconUnique Document ID: 1bfbbff3053c16566449c68c8db3cb9227481919
Timestamp Audit
April 14, 2020 3:05 pm PDTConsent for Services Uploaded by Jason Dooley - jdooley@c-f-d.org IP 173.8.200.225
April 29, 2020 8:42 am PDTRecords Department - records@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
April 29, 2020 9:41 am PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
May 5, 2020 9:26 am PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225
May 5, 2020 9:29 am PDTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225