South Coast Community Services

(877) 527-7227 Phone  |  www.sccs4kids.org

Consent for Treatment for Children

Please review and sign this consent below.  The references below to “You”, “you”, “Your” and “your” mean the Client identified above and signing this Consent below.

1. Services provided by South Coast Community Services (“SCCS”) may include assessment; diagnosis; drug and alcohol testing; crisis intervention; individual, group, or family therapy; medication; day treatment services; training in daily living and social skills; prevocational training; and/or case management services, as determined by SCCS according to the applicable program guidelines and SCCS’s professional judgment. Services are provided by qualified professional SCCS staff members
2. Treatment consists of conversations between qualified professionals and clients, focusing on the presenting problem and associated feelings, possible causes of the problem and previous attempts to cope with it, and possible alternative courses of action and their consequences. The frequency and type of treatment will be planned by you and the treatment staff. Every effort will be made to provide you with services in the language of your choice.
3. You understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders and personal and relational issues, there is no guarantee that all treatment of all clients will be effective.
4. All information and records obtained or created by SCCS in the course of your treatment shall remain confidential and will not be released without your written consent except as specified in the HIPAA Notice of Privacy Practices you were given.  These exceptions to confidentiality include mandatory reporting of child, elder, and dependent adult abuse and any threats of violence you may make towards a reasonably identifiable person, and disclosures required to law or pursuant to lawful subpoenas for administrative proceedings or court cases.
5. You have the right to accept, refuse, or stop treatment, including Telehealth treatments,  at any time.
6. For the duration of treatment, you authorize the applicable county mental health plan to apply for and receive payment of medical benefits from any and all health insurance plans by which you are covered, including Medicare, Medi-Cal and related public payor programs.
7.  You confirm that to the best of your knowledge, you are a Medi-Cal eligible individual, and understand that SCCS has confirmed your Medi-Cal eligibility to the best of its ability. Acceptance and participation in the Medi-Cal behavioral health system is voluntary and is not a prerequisite for access to other community services. You retain the right to access other Medi-Cal reimbursable services and have the right to request a change of provider, staff person, therapist, coordinator, and/or case manager to the extent permitted by law. If for any reason you are subsequently determined not to be Medi-Cal eligible, you may not be able to continue treating with SCCS.  If that happens, SCCS will do its best to refer you to other mental health providers or programs that may be able to provide or continue the treatment you seek.

TELEHEALTH CONSENT

"Telehealth" is a method to deliver health care services using information and communication technologies to facilitate the diagnosis, educate, consult, treat, and provide care management while the client and provider are at different locations within California. This service is usually live interactive videoconferencing through a personal computer with a webcam or with a smartphone (iPhone or Android phone) with a self-facing camera. Telehealth may also include the use of a telephone.

You have the following rights under this consent:

• You have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of your medical information for in-person psychotherapy. Any information disclosed by you during my mental health treatment, therefore, is generally confidential and cannot be released without my written consent. There are, by law, the same exceptions to confidentiality that apply for in-person treatments, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence you may make towards a reasonably identifiable person, and disclosure required by law or pursuant to lawful subpoenas for administrative proceedings or court cases.
• You also understand and agree that if you and/or therapist ever believe your mental or emotional condition to be a potential or actual danger to yourself or others, your provider has the right and duty to break confidentiality to prevent the threatened danger.
• You understand that neither the provider nor you can lawfully record or create any photographs, video recordings, audio recordings and shall not disseminate any photographs, video recordings, audio recordings or personally identifiable images, and/or information from the telehealth interaction outside of required or other permissible healthcare records and documentation.
• You understand that while you may benefit from telehealth, results cannot be guaranteed or assured. You further understand that there are risks unique and specific to telehealth, including but not limited to, the possibility that your therapy sessions or other communications between you and your therapist or between your therapist and others regarding your treatment could be disrupted or distorted by technical failures or, despite use of state-of-the-art encryption and security protocols, might be accessed by the criminal behavior of unauthorized persons.
• At the start of each session, you will inform your provider of your physical location and an emergency telephone number in case of an emergency that could take place during my session.

Therefore, you agree to participate in Telehealth services as outlined above.

CONSENT FOR RECORDINGS AND THIRD PARTY OBSERVATION

I authorize South Coast Community Services (SCCS) to make sound and/or photographic recordings or have third party observations of my clinical sessions (and to have other persons make recordings of such sessions under the direction of clinical staff) while I am under the care of SCCS. It is agreed that these recordings and observations may be used for the following purposes only:

The term “photographic recordings” as used herein includes video or still photography, in digital or any other format, and any other means of recording or reproducing images.

I understand that I may withdraw this consent at any time, with no consequences for my treatment here. If not withdrawn earlier, this consent will expire on

(not longer than one year from the date of signature below). Unless specifically noted above, these recordings will be erased following the use(s) listed above.

APPOINTMENT AGREEMENT

As a courtesy to our mental health team and our other clients, we ask that you provide at least a 24-hours’ notice of cancellation if you cannot make your appointment, so that we may try to offer that appointment to someone else.

It is SCCS policy that your case may be closed if you miss or no-show to two (2) or more consecutive appointments without providing 24-hours’ notice of cancellation, or if there is a pattern of inconsistent attendance for scheduled appointments. Your case may also be closed if SCCS has had no contact with you for a period of thirty (30) days.

SCCS will be using an automated texting system and/or e-mail to assist with confirming your appointments. You consent to and will accept texts and/or e-mail from SCCS for this and any other purpose relating to your treatment.

NOTICE TO CLIENTS REGARDING COMPLAINTS

SCCS has a Compliance Hotline that receives and responds to complaints or concerns regarding the practice of psychotherapy or any other aspect of the services provided by SCCS any team member counselor providing services at South Coast Community Services. To file a complaint, contact (877) 900-8478, or send to  25910 Acero, Suite 160  Mission Viejo, CA 92691.

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of ([include your profession: marriage and family therapists/licensed educational psychologists/clinical social workers/professional clinical counselors]). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.

PROGRAM PARTICIPATION AGREEMENT

Your participation in this program is the key to us helping you reach your goals. The following are requirements for admission to the program:

• You, and your family if they are participating in your treatment, will schedule and follow through with planned meetings.
• You, and your family if they are participating in your treatment, will assist in completing initial paperwork and assessments within the first 30 days of your treatment.
• The following are some of the rights that you have as a client and information that you should be made aware of:
• You have the right to decide not to receive counseling or therapy at SCCS, and may end counseling or counseling at any time. If you wish, SCCS will provide you with the names of other qualified individuals/organizations.
• You have the right to ask any question about the methods used during therapy. Upon your request, a Clinician shall promptly explain the methods used, and other options, if any, available to you.
• The following are some of the initial and ongoing requirements that SCCS has to ensure the safety of you, your family and the SCCS staff or team members.
• You, and your family if they are participating in your treatment, will separate rather than fight or threaten anyone.
• You, and your family if they are participating in your treatment, will disclose to SCCS team members if there are firearms and weapons in the home and agree to disarm and lock them up in a safe, the trunk of a car, taken off site, etc.
• You, and your family if they are participating in your treatment, will lock up or isolate any animal that could be a safety risk.
• You, and your family if they are participating in your treatment, will refrain from being under the influence of alcohol or drugs during the time we work together.
• You, and your family if they are participating in your treatment, will not knowingly expose the team to infectious illness or disease.

ACKNOWLEDGEMENTS

• I acknowledge that I have received a copy of this agreement.
• I acknowledge that I understand, agree with and consent to all of the conditions above.
• I acknowledge that I have received a copy of the Notice of Privacy Practices.
• I acknowledge that I have received a copy of the Mental Health Plan Beneficiary Handbook.

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