• Informed Consent for Psychotherapy Services

    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 grievances and alleged violations of client rights -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
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