Consents for Treatment * * Only the client (if over 18) or legal guardian may complete these documents * * Date MM DD YYYY Client Name * First Name Last Name Client Date of Birth MM DD YYYY Client Social Security Number School & Grade (if applicable) GUARDIAN INFORMATION LEGAL GUARDIAN OF CLIENT IS: Self (over18) - no need to complete guardian info below Biological Parent(s) Adoptive Parent(s) Case Manager Grandparent(s) Non-Relative Placement Other Guardian Name First Name Last Name Guardian Phone Number (###) ### #### Guardian Email AUTHORITY TO CONSENT TO TREATMENT I certify hat I have the legal authority to consent to treatment, release of information, and all legal issues regarding the above-named client. I consent for this client to participate in and receive mental health services from My Tribe Counseling. If I am no longer the guardian of the above client, I will immediately notify My Tribe of my change in status and advise whom the new legal guardian is (if known). I understand that this consent may be revoked for any future services, at any time, in writing. AUTHORITY TO SEE CLIENT IN SCHOOL (if applicable) I authorize My Tribe Counseling, to see the above referenced client at home and in school (if applicable). I understand that Phoenix will comply with all security and confidentiality policies of the school and will do their best to minimize interruption to the client’s school day. Due to the nature of receiving services at school, Protected Health Information (PHI) may be needed to be shared with school staff. CLIENT HANDBOOK ACKNOWLEDGEMENT I confirm that I have received a copy (electronically or paper) of My Tribe Counseling's Client Handbook. Contained within the handbook are the Client’s Rights and Responsibilities, Privacy Practices, Confidentiality policy, and the Grievance Procedure. I understand the contents of the Client Handbook and acknowledge that if I have any questions regarding it, I may contact a My Tribe representative at anytime who will address any concerns or questions that I may have. COORDINATION OF CARE WITH PRIMARY CARE PHYSICIAN Please choose one: I authorize My Tribe Counseling to use and/or disclose certain Protected Health Information (PHI) with my/my child's Primary Care Physician for Coordination of Care I do NOT authorize My Tribe Counseling to contact the Primary Care Physician (PCP) at this time Client does not have a Primary Care Physician (PCP) at this time. I understand the My Tribe Counseling recommends that all clients utilize a PCP for care. Primary Care Physician Name (if applicable) Primary Care Physician Phone Number (###) ### #### Unless other instructions are received in writing, these consents expire 1 (one) year from the date signed below. Client Signature Client Name (Typed) Date Signed MM DD YYYY Guardian Signature (Required if client is under 18) Guardian Name (Typed) Date Signed MM DD YYYY Thank you!
