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• I/We understand that it is our right to receive services, both written and verbal in our preferred language.
• I/We hereby grant permission to Beech Acres Parenting Center to provide mental and behavioral health services as may be deemed medically necessary or advised for diagnosis and/or treatment/care. I/We understand that I/We will be offered the most appropriate and least restrictive services to meet my/our needs.
• I/We hereby grant permission to Beech Acres to treat my child on all topics that may be applicable. Treatment with my child may involve discussion about an array of topics, included but not limited to: depression, anxiety, attention-deficit hyperactivity disorder, obsessive compulsive disorder, gender-related conditions, autism spectrum disorder, oppositional defiant disorder, conduct disorder, bipolar disorder, and personality disorders.
• I/We understand that the clinician/worker will serve us/client in the home, community setting (e.g., schools) and/or office as appropriate in assessing issues, needs, and development of a service plan with goals and objectives, in the aim of resolving problems which I/we define.
• I/We agree to cooperate with the clinician/worker and will participate in the program(s) as necessary.
• I/We have been fully informed aboutservice options, benefits, risks, and alternatives, and understand that I/we will be involved in setting and modifying service goals and in making decisions about the services we receive.
• I/We understand that I/we must provide 24-hour advance notice of cancelled appointments.
• I/We understand that Beech Acres Parenting Center reserves the right to terminate, discharge, dis-enroll, and/or reduce services if there is a lack of contact/participation and/or failure to respond to efforts of engagement. I/We understand that such would not occur without advanced written notice and an opportunity to appeal such decision.
• I am/We are aware that Beech Acres Parenting Center cannot share information outside of the agency without my/our written authorization, except as required or allowed by law in an emergency situation to assist in my/our continuum of care or to ensure safety in a situation deemed life threatening, or under state law in cases of suspected child abuse or neglect, or as allowed by regulatory bodies and contractual obligations permitted under law.
• I/We understand that only the parent or legal guardian (or someone to whom the parent or legal guardian has delegated his/her powers regarding the care or custody of the minor(s) as evidenced through official legal documentation) can provide consent for services, and I/we have provided documentation ofsuch. I/We understand that Ohio law permits minors fourteen (14) years of age and older to consent to outpatient mental health services without the consent of parental or guardian. If the services rendered pursuant to this consent are limited to such outpatient mental health services, I/we understand that the minor patient may provide this consent on the minor’s own behalf upon minor’s presentation of documentation confirming age.
• If any proposed treatment/service is of a specialized nature with associated risks, those risks will be discussed verbally with me and outlined on a separate form requiring my signature.
• I/We understand that I am/We are consenting to services by Beech Acres Parenting Center. I/We understand that consent is voluntary and may be withheld or withdrawn at any time. I/We understand that I/We may refuse any service, treatment or medication unless mandated by law or court order. I/We understand this consent is valid for one year from date of signature obtained on the intake signature page.