We welcome you and your family members to our practice. We will do everything in our professional capacity to make
the treatment as productive as possible. Please find displayed patient’s rights and responsibilities in our office.
It is understood that all information between patient and Psychiatrist/Therapist is held in strict confidentiality, and
Psychiatrist/Therapist will not release any of that information unless permitted by law, or;
1. It is agreed upon in writing and complies by state law
2. The patient presents an imminent danger to self or others
3. Child/Adult neglect is suspected
4. Is necessary for continuity of care
5. A judge chooses to subpoena the records
6. As requested by a court appointed attorney for a child involved in court proceedings
Patient consent to release of information
I consent to information release about my (or my child's) case with the referral source and co treating health care
providers and facilities for purpose of treatment, payment and Health Care Operations. I further consent to the release
of information to my health plan for claims, certification/ case management/ quality improvement and other health plan
General consent for treatment
I further authorize and request that my psychiatrist/therapist carry out psychological examinations, treatment and/or
diagnostic procedures that now or during the course of my care as a patient is advisable. I understand that the
purpose of these procedures will be explained to me upon my request and subject to my agreement. I also
understand that while the course of therapy is designed to be helpful, it may be at times difficult and uncomfortable.
General consent for treatment (for minor)
On patient's behalf, (the legal guardian or Legal Representative) authorize SCPC to deliver mental health services to
the patient. I understand that all policies stated on this page apply to the patient. I accept that child's records are
confidential and that by law, I cannot have access to the child's records if such access would be deemed as
detrimental to the child.