1. Consent to Evaluate/Treat:
I voluntarily consent that myself or my child will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or treatment by staff from The Lotus Heart, LLC. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:
a. The benefits of the proposed treatments.
b. Alternative treatment modes and services.
c. The manner in which treatment will be administered.
d. Expected side effects from the treatment and/or the risks of side effects from medications
(when applicable).
e. Probable consequences of not receiving treatment.
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The evaluation or treatment will be conducted by a psychotherapist, a psychologist, a psychiatric nurse practitioner, a psychiatrist, a licensed therapist or an individual supervised by any of the professionals listed. Treatment will be conducted within the boundaries of Ohio Law for Psychological, Psychiatric, Nursing, Social Work, Professional Counseling, or Marriage and Family Counseling.
2. Benefits to Evaluation/Treatment:
Evaluation and treatment may be administered with psychological interviews, psychological assessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to myself or my child, as well as the referring professional, to understand the nature and cause of any difficulties affecting myself or my child’s daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic performance, health status, quality of life, and awareness of strengths and limitations.
3. Charges:
Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. I will be responsible for any charges not covered by insurance, including co-payments and deductibles. Fees are available to me upon request.
4. Confidentiality, Harm and Inquiry:
Information from myself or my child’s evaluation and/or treatment is contained in a confidential medical record at The Lotus Heart, LLC, and I consent to disclosure for use by The Lotus Heart, LLC staff for the purpose of continuity of myself or my child’s care. Per Ohio mental health law, information provided will be kept confidential with the following exceptions: 1) if my child is deemed to present a danger to himself/herself or others; 2) if concerns about possible abuse or neglect arise; or 3) if a court order is issued to obtain records.
5. Right to Withdraw Consent:
I have the right to withdraw my consent for evaluation and/or treatment for myself or my child at any time by providing a written request to the treating clinician.
6. Expiration of Consent:
This consent to treat will expire 12 months from the date of signature, unless otherwise specified.
I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment of myself or my child. I also attest that I am the legal guardian and have the right to consent for the treatment for my child. I understand that I have the right to ask questions of my child’s service provider about the above information at any time.
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Please complete the online consent for treatment form. CLICK HERE