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Informed Consent For Participation in Mental Health Services

The document is an informed consent form for participation in mental health services. It states that the client has received information about their rights and has agreed voluntarily to receive services. The client also agrees to follow the agency's participation expectations and understands they can withdraw from services at any time. The client consents to the health center contacting them by phone for follow-up purposes like billing. Signatures are required from the client, guardian if client is a minor, and a staff member.

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Noreen Punjwani
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221 views1 page

Informed Consent For Participation in Mental Health Services

The document is an informed consent form for participation in mental health services. It states that the client has received information about their rights and has agreed voluntarily to receive services. The client also agrees to follow the agency's participation expectations and understands they can withdraw from services at any time. The client consents to the health center contacting them by phone for follow-up purposes like billing. Signatures are required from the client, guardian if client is a minor, and a staff member.

Uploaded by

Noreen Punjwani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INFORMED CONSENT FOR PARTICIPATION IN MENTAL HEALTH

SERVICES

As a client of AMITA Health Center for Mental Health, I have received a copy of my
rights and have had the opportunity to ask questions about the services I may receive. I
am agreeing voluntarily to receive and participate in mental health services at Alexian
Brothers Center for Mental Health. I am also agreeing to follow the agency expectations
for participation in mental health services. I understand that I may choose to withdraw
from services at any time in the future.

I expressly consent for AMITA Health Center for Mental Health, its providers and agents
to place calls to my cellular and/or residential phone using artificial or pre-recorded
voice or auto-dialer technologies for any follow-up purposes, including billing and
collections.

__________________________________ ________________
Client signature (age 12 or older) Date

__________________________________ ________________
Guardian signature (required if client is under 18) Date

__________________________________ ________________
Staff signature Date

Note: Consent must be obtained prior to the initiation of mental health services.

Date Guardian notified of need for signature: ________________________________

CENTER FOR MENTAL HEALTH Client Name ______________________________________


3436 N. Kennicott Avenue Client I.D.# _____________________________________
Arlington Hts., IL 60004
M:\Forms-ABCMH\Opening Paperwork\InformedConsent Rev 09/19

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