Submit
Cancel

Intake B -Consent to Treatment I

LifeBack
4 Princess Rd
Suite 206
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
I, the undersigned, hereby attest that I have voluntarily entered treatment or have given my consent to treatment for the minor or person under my legal guardianship named above at LifeBack Addiction and Behavioral Health, hereby referred to as the Center.  Further, I consent to have treatment provided by a; psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. The rights, risks, and benefits associated with the treatment have been explained to me. I understand that treatment may be discontinued at any time by either party. The Center encourages that a decision to discontinue treatment be discussed with the treating provider(s) to facilitate the most appropriate plan for referral or discharge.
Patient's Rights: I certify that I received a copy of the Patient's Rights and that I have read and understand its content.
I am aware and agree that if I am admitted to a NJ substance use recovery program my information will be entered into the NJ statewide system NJSAMS.
Client Notice of Confidentiality: The confidentiality of patient records maintained by the Center is protected by federal and/or state law and regulations. Generally, the Center may not disclose any information about persons receiving substance abuse treatment to a person outside the Center unless:
(1) the patient consents in writing,
(2) there is reason to suspect that the patient is at imminent risk of harming themself or another person,
(3) there is reason to suspect that the patient is or has engaged in child and/or elder abuse,
(4) disclosure is needed to be provided to medical personnel in a medical emergency,
(5) the disclosure is allowed by a court order, or
(6) to qualified personnel for research, audit, or program evaluation.
Suspected professional misconduct by a health care professional must be reported by other health care professionals, in which related client records may be released to substantiate disciplinary concerns. Violation of federal and/or state law and regulations by a treatment facility or provider carries criminal and civil penalties. Federal and/or state law and regulations do not protect any information about a crime committed by a patient either at the Center, against any person who works for the Center, or about any threat to commit such a crime.
It is the Center's duty to warn any potential victim(s) when a significant threat of harm has been made by a patient.
When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about the client, not clinical information.
Signature
Signer Type:
Name:
Signature:
Sign with Touch
 
Comments:
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.