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Consent testing

1258 High Street, Eugene, OR 97401

Phone 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 Age 14 or Older

I have the right to access mental health and substance use disorders services without consent from my parent / legal guardian.
My parent(s) / legal guardian(s) 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.
Treatment Records:
- Mental Health Child Program: My parent(s) / legal guardian(s) have the legal right to obtain records about my treatment, including notes about my sessions, unless there are clinical reasons not to provide records, which will be documented in my record.
  - Parent / Legal Guardian: Unless otherwise ordered by the court, biological parents have the legal right to obtain records about their child’s services in the Mental Health Child Program, even if the parents are not involved in services. Records include therapy session notes, which may have information shared by one parent about the other parent.
- Youth Recovery Program: Records about my treatment cannot be disclosed without my written consent, including to my parent(s) / legal guardian(s).

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.
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: 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 (for Adults)

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.

Does not apply (youth only)

Advance Directive (for Adults)

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 statement 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.

Does not apply (youth only)

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.

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: 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:

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.

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Your legal name

Your email address

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March 21, 2023 1:36 pm PDT

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March 21, 2023 1:37 pm PDT

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