Informed Consent for Assessment and Treatment Child-1
This document contains important information about our services and operation policies. Please read it carefully, and note any questions you might have so that you can discuss them with your clinician. When you sign this document, by electronic (e-sign: full name in conjunction with providing specific identifying information) or physical signature, it will represent an agreement between you and Pursuit of Happiness.
Section A
Please place your initials in the box below indicating that you have thoroughly reviewed and understand the above disclosure. *
Your answer
Please type in name of Patient below *
Your answer
Place initials in the box below *
Your answer
Section B
I understand that as a legal guardian of a Patient of Pursuit of Happiness I may be eligible to receive a range services. The type and extent of services that I will receive will be determined following an initial assessment and thorough discussion with me. The goals of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

I understand that services will be provided by a Licensed Professional Counselor (LPC). Information shared with my LPC is confidential and no information will be released without my consent other than to the Director of Mental Health Services of Pursuit of Happiness. In all other circumstances, consent to release information is given through written authorization signed by me. Verbal consent for limited release of information may be necessary in special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which, according to Texas statutes, include the following:

*When there is imminent risk of danger to the Patient or others, clinician is ethically bound to take appropriate necessary steps to prevent such danger.
*When there is a suspicion that a child, elderly, or someone who cannot otherwise protect themselves from physical or sexual abuse, clinician is legally required to take steps to protect the victim, and to inform the proper authorities.
*When a valid court order is issued for specific medical records, or if records are subpoenaed, the clinician and the agency are bound by law to comply with such requests.

I understand that while psychotherapy and counseling may provide significant benefits, it may also pose risks. Psychotherapy and counseling may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories. Psychotherapy calls for a very active effort on the part of both the clinician and the client in order to be most successful. I understand that the Patient will have to work on things we talk about both during our sessions and at home.

I understand that all services are provided by Licensed Professional Counselors (LPC) who practice with a license governed by the Texas State Board of Examiners of Professional Counselors, which is a division of Texas Department of State Health Services, and that all therapists with Pursuit of Happiness are independent contractors.

I understand that if I miss two consecutive appointments without notifying my clinician, or if I become non compliant with services as judged by my clinician, Pursuit of Happiness reserves the right to refer my case elsewhere and my case will be closed with Pursuit of Happiness, and this behavior will be reported to any case managers or placement agencies that I am working with. I understand that in order to reopen my case with Pursuit of Happiness, I must reapply for services.

I understand that if I cancel or do not show up to my appointment, and do not give at least 24 hours notice, I will not receive a refund, and I will be responsible for the payment of that session, unless I am a Medicaid recipient. I understand that cancellations made up to three days in advance are eligible for a refund of fifty percent and that I am responsible for fifty percent of the regular payment, and cancellations greater than three days are eligible for a full refund. I understand that all refunds for cancellations of appointments are at the sole discretion of Pursuit of Happiness.

I understand that if I carry commercial insurance, and I cancel within 24 hours of scheduled appointment, that I am responsible for the full payment of services consistent with my insurance carrier's contracted rate for reimbursement. If I cancel within three days of an appointment, I am responsible for 50% of my insurance carrier's contracted rate for reimbursement. I understand that all billings for cancellations of appointments are at the sole discretion of Pursuit of Happiness.

If I am covered by traditional Medicaid, Superior, Parkland Medicaid, Cook Childrens Medicaid, Childrens Medicaid, CHC Medicaid, or Sendero Health Options Medicaid, I understand that, in the opinion of Pursuit of Happiness, the services or items that I have requested to be provided to me on my dates of service may not be covered under the Texas Medical Assistance Program as being reasonable and medically necessary for my care. I understand that the HHSC or its health insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care, or if I have switched Medicaid providers to a managed care organization that Pursuit of Happiness is not in network with, and have continued to receive services, and failed to alert Pursuit of Happiness to this change in insurance coverage.

I understand that Pursuit of Happiness operates a limited number of hours per week. If I have an emergency situation, I may leave a message on my clinician’s voicemail to try to schedule an immediate appointment. Unless otherwise discussed with my clinician, on nights and weekends I will contact my family physician or the nearest emergency room and ask for the psychologist/psychiatrist on call. PURSUIT OF HAPPINESS DOES NOT OFFER 24 HOUR CARE.

If I have any questions regarding this consent form or about the services offered by Pursuit of Happiness, I may discuss them with my therapist. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by Pursuit of Happiness. I understand that I may stop treatment at any time.

Section C
I HAVE READ AND UNDERSTAND THE CURRENT PURSUIT OF HAPPINESS PROCEDURES STATED ABOVE. I UNDERSTAND THE LIMITS TO CONFIDENTIALITY AND THE PATIENT’S RIGHTS AND RESPONSIBILITIES. I HAVE VERBALLY COMMUNICATED ALL CONCERNS WITH MY CLINICIAN.
Please type FULL NAME of Legal Guardian in box below *
Your answer
To validate your identity, please type in the last 4 digits of Legal Guardians Social Security Number. *
Your answer
Current Month *
Today's Date *
Current Year *
ex: 2010, 2012, etc
Your answer
***IMPORTANT***
Please save or print a copy of this informed consent for your records.
Submit
Never submit passwords through Google Forms.
This form was created inside of Pursuit of Happiness. Report Abuse - Terms of Service