For Printable PDF, click here. Informed Consent for Psychotherapy Client's Name(Required) First Last Is the Patient under 18 years old?(Required) Yes No Parent/Guardian Name(Required) First Last Email(Required) Informed Consent for Treatment - Psychotherapy I understand that as a client at Zumbro Valley Health Center, I am eligible to receive a range of services. The type and extent of services that I will receive will be determined following an initial diagnostic assessment or psychiatric evaluation and through discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks, or months, and is most beneficial when scheduled appointments are attended. Zumbro Valley Health Center Customer Service completed a Financial Intake with me before meeting my clinician. At this time fees for services, third-party payment coverage, and when applicable, Sliding Scale eligibility were discussed. I received the following documents at that time: The Notice of Privacy Practices Financial Agreement Grievance/Complaint Procedure Client Rights and Responsibilities Government Data Practices Act and procedures for reporting Attendance Policy As part of the informed consent process, my clinician reviewed and answered my questions regarding the following topics: Limits of confidentiality and mandated reporting Identification of licensure Treatment alternatives Possible outcomes Side effects of treatment Approximates length and cost of treatment Client's rights and responsibilities in implementation of the treatment plan Staff rights and responsibilities in the treatment process Attendance Keeping scheduled appointments is very important to the process of treatment. The Zumbro Valley Health Center Psychological Services requires appointments to be canceled or rescheduled no less then 12 hours prior to the appointment time. Clients who have two no-show appointments will receive communication (phone call, letter or email) outlining the Missed Appointment Policy. Clients who have three no-show appointments within six months period may be discharged at the program's discretion. For further questions, please follow-up with your individual provider. Psychotherapy clients will be consider inactive after not attending an appointment for fifty consecutive days. Psychiatry clients will be considered inactive after not being seen in the program for a duration of six months. The client will then be discharged from the program and will no longer be considered an active client. Services may be re-established upon the client contacting Customer Service and taking the necessary steps to reengage in care.Uses of Technology, Email, and Social Media Zumbro Valley Health Center does not promote the use of email communication. Email may not be confidential or reliable for communication between sessions. The best way to be in contact is by telephone. Zumbro Valley Health Center maintains an agency social media policy that prohibits contact between staff and clients. Client privacy and professional boundaries are priorities and can become too easily compromised through use of any social media sites. By signing this document, I am stating I have been provided this information and have had the opportunity to ask questions and have those questions answered.
