Mid-Ohio Behavioral Health, LLC
CONSUMER’S CONSENT & ACKNOWLEDGEMENTS
CONSENT FOR TREATMENT: I hereby consent to treatment from Mid-Ohio Behavioral Health, LLC (MOBH) for myself or for the person whom I am the legally authorized representative. I understand that MOBH services are provided by a variety of mental health professionals. (MOBH may also provide some services by “professionals in training” which are supervised by licensed or certified professionals).
I understand that, while mental health treatment may provide significant benefits, it also poses some risk. Psychotherapy may cause thoughts, feelings, or memories to surface which may be uncomfortable or even painful. Medications prescribed by a physician or nurse practitioner may have side effects. I also understand that during my treatment MOBH may provide telehealth or telephone services. Where the provider and the patient may not be in the same physical location. MOBH may also provide psychological, educational and neurological testing during my treatment. I acknowledge that no guarantee has been made to me concerning the effect of treatment. My signature below indicates that I have reviewed and understand this Consent for Treatment and that I consent to treatment by Mid-Ohio Behavioral Health, LLC.
HIPAA NOTICE OF PRIVACY PRACTICES: I hereby acknowledge that I have been informed of the HIPAA Privacy Practices of Mid-Ohio Behavioral Health, LLC and chose to either keep a copy for my records or agreed to call 740-569-5737 if I want to review the notice again or file a violation complaint.
CLIENT RIGHTS POLICY: I hereby acknowledge that I have received a copy of Mid-Ohio Behavioral Health, LLC’s Client Rights Policy. I UNDERSTAND THAT THE CLIENT RIGHTS OFFICER IS TERESA NORRIS AND SHE CAN BE REACHED AT 740-569-5737.