Form Test

On behalf of myself or my minor child or other individual named below, I acknowledge and consent to the statements made in this form. I am requesting that behavioral health services be provided to me (or my minor child or other individual named below) by OhioGuidestone and its subsidiary organizations (collectively, "Agency"). I voluntarily consent to all behavioral health services, including substance use disorder services, and behavioral health-related services that providers at the Agency consider necessary. These services may include care coordination, diagnostic, therapeutic, pharmacological and laboratory services.

I understand that behavioral health services can have both benefits and risks. The risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, as behavioral health services may require discussing challenging or unpleasant life events. For children and adolescents this may manifest in behavioral reactions. I also understand, while no specific outcome is guaranteed, that the benefits of behavioral health services may include a reduction in feelings of anger or distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased feelings of well-being, increased skills for managing stress, and resolutions to specific problems. I am aware that I have the right to refuse or withdraw consent for behavioral health services at any time and that I am responsible for the potential consequences of such refusal or withdrawal.

If appropriate, I understand that I (or my minor child or other individual listed below) may be referred for pharmacological evaluation and intervention (the use of medication). I understand that I have the right to refuse to take specific medications, or to participate in specific treatment options. In the event I choose to reject a treatment recommendation, my provider will explain the possible consequences of this refusal and the risks of alternative treatment options, or no treatment.

I understand that the Agency may wish to provide treatment or services to me or my minor child (or other individual named below) using telehealth. Telehealth is the form of telemedicine that allows clients to access behavioral health care using audio and/or audio/video interface technologies such as videoconferencing and telephone. The Agency has explained to me how telehealth technology will be used to provide treatment and services.

I understand the expected benefits of telehealth may include improved access to services; additional convenience for the client; more efficient management of behavioral health services; and obtaining the expertise of a distant specialist. The potential risks to telehealth technology may include technological difficulties that disrupt effective and timely communication or service delivery and unauthorized access causing a breach of privacy of protected health information. I understand that my use of a public computer, a device on a shared network, use of non-encrypted communication, or auto-fill features all present risks to the security of my private information. I have discussed the technology requirements necessary for my telehealth service. I understand that there is a possibility of technology failure during a service and will follow the service disruption procedure in case of such a failure. The Agency or I can discontinue the telehealth appointment if the technology connections are not adequate for the situation.

I am aware of anticipated response times to electronic communication, alternative service deliveries, and expectations regarding electronic communication between scheduled appointments and outside of normal business hours. I understand that the Agency cannot ensure confidentiality (1) at a non-Agency site; (2) when non-Agency equipment or software is used; or (3) when Agency telehealth procedures are not followed. I understand these risks and I agree to assume these risks for any telehealth services I may receive. I consent to participate in telehealth services. I understand that I have the right to withhold or withdraw consent to the use of telehealth at any time, without affecting the right to future care or treatment.

I consent to receive email messages and text messages, including automated messages, from Agency. These messages may contain my protected health information. I am aware that text messages are not secure and there is a risk a text message could be read by a third party. By choosing to receive text message from Agency, I acknowledge and accept the inherent risks of text messages.

If I do not wish to consent to email messages or text messages, I may opt out by notifying my provider or the Agency Privacy Officer.

In the event of an emergency, I understand I should call 911 or go directly to my nearest emergency room.

I understand that my Personally Identifiable Information and Protected Health Information will be kept confidential as required by federal and state law. The Health Insurance Portability and Accountability Act (HIPAA) is a federal law. The HIPAA regulations, in conjunction with state law, determine how my Protected Health Information (PHI) can be used or disclosed. The Agency may use or disclose my PHI as set forth in the Notice of Privacy Practices, including for treatment purposes, payment purposes, and as necessary for the operations of the Agency. I understand that the laws that protect the privacy and confidentiality of PHI also apply to services provided via telehealth.

I have received a copy of the Notice of Privacy Practices, as required by HIPAA, which includes a notification of 42 CFR, Part 2, which explains the privacy rules that apply to Substance Use Disorder Treatment Services. If applicable, I have received a copy of the Notice of Privacy Practices of the Alcohol, Drug Addiction, and Mental Health Board that is paying for part or all of my services. I am aware that I may request that my HIPAA privacy rights be discussed with me verbally and have been given the contact information of the Agency Privacy Officer, so that I may contact her/him with any questions I may have.

The Client Rights were explained to me, and I have received a copy of the Client Rights and Grievance Policy. I am aware that I have a right to contact the Client Advocate if I have any concerns.

Lastly, I have received a copy of the Expectations for Participation in Programs and Services. I understand and agree to do what is expected of me while receiving these services.

I understand that I can receive an additional copy of any of the above documents at any time, at my request.

I am a minor between 14 and 18 years of age and the above information has been explained to me. I understand that I may receive services from the Agency without parent/guardian consent for up to 30 days or 6 sessions whichever comes first. After the sixth session or thirty days of services my provider shall terminate the services or, with my consent, notify my parent, or guardian, to obtain consent to provide further outpatient services. I understand that my parent or guardian will be notified of my services if my provider determines I pose a danger of harm to myself or others.

By clicking the "Submit" button, you agree to use electronic records and signatures. At any time, you may request a paper copy of any record provided or made available electronically to you by us. You will have the ability to receive email copies of documents you have submitted by entering your email address during the document submission process. If you do not have an email address, PRINT A COPY OF THIS RECORD prior to submission. If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can deliver services to you and complete certain steps in transactions with you. Further, you would no longer be able to use the OhioGuidestone Website eSignature System to receive required notices and consents electronically from us or to electronically sign documents from us. This consent to use of electronic records and signatures will apply to this and future records sent electronically to you by us. You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies, and to withdraw your prior consent to receive notices and disclosures electronically by sending an email to Compliance@OhioGuidestone.org.

The minimum system requirements for using the OhioGuidestone Website eSignature System may change over time. By clicking “Submit,” you agree that until or unless you notify us as described above, you consent to receive exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of your relationship with OhioGuidestone.