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TELEHEALTH CONSENT FORM

Telemedicine PACKET Adult / Child

(To be explained to staff and signed by Individual, then FILED IN CHART

Individual will be given “Individual Orientation” at intake)

SUMMARY OF INDIVIDUAL RIGHTS IN COMMUNITY MENTAL HEALTH, AND SUBSTANCE ABUSE

(Provide Client Copy)

When you receive services in a community mental health, mental retardation, and/or substance abuse program, your rights are protected by Rules and Regulations contained in Chapter 290-4-9. A full copy of the Rules is available to you at the program where you are served. Below is a simplified outline of those rights. The Rules and Regulations describe any limitation to these rights and other provisions, which may apply and should be consulted when there is a dispute or question regarding any of these rights.

 

Your rights include:

● The right to an interpreter if you do not speak English or are hearing impaired.

● The right to receive services that respect your dignity, and protect your health and safety

● The right to know the names and positions of all those involved in services planning and implementation process

● The rights to be informed of the benefits and risk of your treatment.

● The rights to participate in planning your own program.

● The right to refuse service, unless a physician or licensed psychologist feels that refusal would be unsafe for you or others.

● The right to receive care suited to your needs.

● The right to prompt and confidential services even if you are unable to pay.

● The right to review and obtain copies of your records, unless the physician or other authorized staff feels it is not in your best interest.

● The right to exercise all civil, political, personal and property rights to which you are entitled as citizen.

● The right to be free of physical or verbal abuse.

● The right to converse privately, to have reasonable access to a telephone, to receive/send mail, to have visitors and to retain your personal effects, clothing and money, except if denial is necessary for treatment/rehabilitation-documented by physician/licensed psychologist.

● The right to have advance directives, such as a living will, health care proxy, or durable power of attorney that clearly states your treatment wishes.

● The right to file a complaint if you think any of these rights have been restricted or denied.

 

If you want to know more about your rights, a full copy of the Regulations is available to you on report. A summary of the Individual Rights Complaint Process is also available.

 

The Individual/Legal Representative has had an opportunity to read, or have read to him/her, the above form and ask questions regarding the data contained therein and has in this staff member’s presence.

SAFETY PLAN - CRISIS PREVENTION PLAN

PROBLEM BEHAVIORS: These are behaviors I sometimes show, especially when I’m stressed:
TRIGGERS: When these things happen, I am more likely to feel unsafe and upset:
WARNING SIGNS: These are things other people may notice me doing if I begin to lose control:
INTERVENTIONS: These are things that might help me calm down and keep myself safe when I’m feeling upset: (Check off what you know works; star things you might like to try in the future)
THINGS THAT MAKE IT WORSE: These are things that do NOT help me calm down or stay safe: