Consents and Forms |
Forms and Clinical Records
You will be provided with a copy of your Initial and Individual Treatment Plans. Your clinical record is the property of Sigma Center for Counseling and may be available for your review. A written request is required to get copies and the cost is $1.00 per page. Clinical Records are maintained for seven (7) years. There is a $35 fee to print and send your complete record to whom you designate in writing. Allow two weeks for the process. Informed Consent for Assessment and/or Treatment TO THE CLIENT: You have the right, as a client, to be informed about the results of assessments performed, the nature of identified conditions, and any recommended treatments for identified conditions so that you may make an informed decision whether or not to participate in treatment. ALTERNATIVES: Information about local self-help programs is available from your counselor. Some referral sources require counseling and may not recognize a self-help program as satisfying the requirement for counseling. You may elect to attend a self-help program that will meet your needs. THE NAME OF COUNSELOR WHO HAS PRIMARY Responsibly FOR YOUR CARE: Sigma Center for Counseling, assumes primary responsibility for your substance abuse treatment care in a multidisciplinary team. Your primary counselor ________________________, he/she will serve as your advocate and deliverer of substance abuse treatment services. ATTESTMENT: Informed Consent for Testing Urine/Saliva and/or Breath Screening for Drugs and/or Alcohol Limits of Confidentiality Policy Confidential communication remains the right of all clients of professional counselors according to law. However, there are limits to such communication some of which are mandated by state law. It is very important that you and those seeking counseling with you carefully read and understand the following limits of confidentiality. Duty to Warn Some courts have held that if an individual intends to take harmful, dangerous, or criminal action against another human being, or against himself or herself, it is the counselor's duty to warn appropriate individuals of such intentions. Those warned may include a variety of persons such as: 1. Law enforcement and medical emergency officials. 2. The person who is likely to suffer the results of harmful behavior. Child Abuse Florida state law mandates the reporting of incidence or suspected incidence of child abuse including physical abuse, sexual abuse, unlawful sexual intercourse, neglect, and emotional and psychological abuse. All actual or suspected acts of child abuse will be reported to the appropriate agencies. "Dependent Adult" and Elderly Abuse Florida law requires that incidences of ?dependent adult? or elderly physical abuse reported to your counselor must also be reported to authorities. Case Evaluation In order to ensure the best treatment possible for each client, staff at Sigma Center for Counseling will consult with each other regarding cases. This is traditional in both out?patient and in-patient counseling facilities and is referred to as "case conference" or "peer review." If you have any concerns regarding this practice, please notify your counselor. Confidentiality in Group Confidentiality in the group setting is of the utmost importance. It is imperative that all participants in group feel free to express their thoughts and feelings without fear of repercussion. Any information shared in group should stay within the group. If legal reporting is required, it will be handled by the counselor in charge. Anyone disregarding this policy will be dismissed from group and potentially from treatment. Sigma Center for Counseling cannot be held responsible for information shared in the group setting; however we are dedicated to ensuring dignity and respect for every client. Neglect of Outstanding Debt In the event that a client fails to honor (after reasonable efforts to collect) his/her financial obligation, Sigma Center for Counseling may place the account in the hands of an agency or attorney for collection or legal action. This will necessitate the release of pertinent demographic information as well as accounting information. NO THERAPEUTIC INFORMATION WILL BE RELEASED. Please be sure that you have read the above very carefully. If you are not sure that you fully understand any of the above areas of confidentiality limitations, please ask your counselor before you sign below. I, the undersigned, have read and fully understand the limits of my/our confidentiality. I further agree to abide by the policy set out above. I have had a chance to ask my/our counselor for additional clarification regarding the limits of confidentiality. FINANCIAL AGREEMENT The following constitutes an agreement between the undersigned Client or guarantor and Sigma Center for services rendered by staff of Sigma Center for Counseling. ACCEPTANCE OF FINANCIAL RESPONSIBILITY I accept responsibility to pay by cash, check or money order before each service is rendered. I also, understand that a $35.00 fee will be assessed for all returned checks. The second returned check will be turned over to the District Attorney for issuing fraudulent checks. MISSING APPOINTMENTS / GROUPS I understand that if I have an appointment and fail to cancel it at least twenty-four hours in advance, during the business hours of this office that I will be charged for the service that was scheduled to be delivered. Additionally, a missed appointment fee will be charged to my account. REQUEST FOR FINANCIAL ASSISTANCE
I elect to enter into this agreement freely and understand that I am financially responsible for all services provided.
All outstanding balances must be paid in full before any completion documentation is processed. |
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Sigma Center for Counseling
1727 Blanding Blvd., Suite 105, Jacksonville, FL 32210
English & Spanish Phone: (904) 981-9881
Fax: (904) 981-9883 |
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