Mental Health Acknowledgment and Consent Form
This Mental Health Acknowledgment and Consent form outlines essential patient care practices and confidentiality rights. It serves as a guide for new patients at the SEL Health Clinic. Ensure you understand your rights and responsibilities before signing.
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How do I fill this out?
To fill out this form, carefully read each section to understand your rights and responsibilities. Fill in your personal details accurately and provide your signature where indicated. Review the consent statements thoroughly before submission.
How to fill out the Mental Health Acknowledgment and Consent Form?
1
Read the entire form, especially the confidentiality and consent sections.
2
Fill out your personal information including name and date of birth.
3
Provide any required initials and signatures in the designated areas.
4
Review the form for accuracy to ensure all information is complete.
5
Submit the form as per the provided instructions.
Who needs the Mental Health Acknowledgment and Consent Form?
1
New patients seeking mental health services at SEL Health Clinic need this form.
2
Parents or guardians of minors requiring mental health counseling must complete this form.
3
Individuals transferring from another clinic to ensure continuity of care.
4
Patients wanting to understand privacy practices related to their health information.
5
Anyone looking to authorize the release of their health information for treatment purposes.
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What are the instructions for submitting this form?
Submit your completed form via email at info@selhealthclinic.com or fax it to 509-339-2702. You may also deliver it directly to one of our locations at 2560 NE Hopkins Court, Pullman, WA 99163, or 2857 Juniper Drive, Lewiston, Idaho 83501. For any queries regarding submission, please contact our office directly.
What are the important dates for this form in 2024 and 2025?
Patients should be aware of important dates related to their clinical progress and follow-up appointments in 2024 and 2025. Be prepared for specific deadlines regarding consent renewals and treatment evaluations. Always check with SEL Health Clinic for any updates that may affect your care schedule.
What is the purpose of this form?
The purpose of this form is to provide patients with a clear understanding of their rights and the clinic's confidentiality policies. It establishes consent for treatment and outlines the procedures for releasing health information. By signing this form, patients acknowledge their role in the treatment process and agree to abide by the clinic's policies.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Full name of the patient seeking services.
- 2. Date of Birth: Patient's date of birth for identification purposes.
- 3. Consent Signature: Signature indicating consent to treatment.
- 4. Guardian Signature: Signature of a parent or guardian if the patient is a minor.
- 5. Health Information Release: Authorization for the disclosure of health information.
What happens if I fail to submit this form?
Failure to submit this form could lead to delays in receiving necessary mental health services.
- Delayed Treatment: Without this form, your treatment may be postponed.
- Incomplete Records: Lack of consent may result in incomplete patient records.
- Communication Issues: Failure to authorize information sharing can hinder communication with healthcare providers.
How do I know when to use this form?
- 1. Initial Enrollment: New patients must complete this form before receiving services.
- 2. Authorization for Minors: Parents/guardians need to fill it out for minors seeking treatment.
- 3. Update Patient Information: This form is also used to update any changes in the patient's health information.
Frequently Asked Questions
How can I edit this form?
You can edit this form by uploading it to PrintFriendly and using our intuitive editing tools.
What should I do if I miss an appointment?
If you miss an appointment, please contact SEL Health Clinic within 2 business days to reschedule.
Can I sign the form electronically?
Yes, you can add your signature electronically using PrintFriendly's sign feature.
Is my personal information secure?
We prioritize the confidentiality of your information and ensure secure handling of your data.
How do I submit the completed form?
You can submit the completed form via email, fax, or directly at the clinic's physical address.
What happens if I do not submit this form?
Failure to submit this form may delay your access to necessary health services.
Is there a late policy for appointments?
Yes, if you are late by 10 minutes or more, your appointment may be canceled.
Can I share this PDF with someone else?
Yes, you can easily share your PDF through the PrintFriendly sharing options.
What if I need to revoke consent?
You can revoke your consent in writing at any time except for disclosures made prior.
Can I request changes to my treatment plan?
Yes, you are encouraged to discuss any changes you wish to make to your treatment plan with your provider.
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