GENERAL CONSENT
In accordance with existing law, the nature and purpose of the proposed evaluation (which may include psychological testing) and psychotherapy, medication, case management, alternative therapies, other treatment methods including the alternative of no therapy, have been discussed and explained to me and I understand the risks involved. I consent to and authorize the following procedures necessary for my health and well being:
- Acceptance and participation in the Mental Health System is voluntary and shall not be considered a prerequisite for access to other community services.
- You are informed of services that can or will be provided.
- You receive any of the above services without being required to receive other services from the Orange County Mental Health System.
I understand that he/she has the right to request a change in services providers or withdraw this consent at any time.
CONFIDENTIALITY AND LIMITS OF CONFIDENTIALITY
Korean Community Services (KCS Health Center) strictly adheres to the confidentiality of information presented by and pertaining to its clients. What is revealed in a therapeutic setting is protected by legal, professional, and ethical standards, such that with a few important exceptions, all materials are confidential and not released without your written consent.
There are, however, limits to confidentiality in which the professional you see is ethically and legally required to report what you disclose without your consent. For instance, if you state that you plan to harm yourself, or there is a reasonable possibility of harming others, then the therapist or psychiatrist you see is responsible to report this in order to protect yourself or others from harm. Also, the State of California requires that if it is known, or there is a reasonable possibility of, child abuse, spouse abuse, or dependent adult/elder abuse, this must be reported to the appropriate authorities. The limits of confidentiality include: 1) Harm to yourself 2) Harm to another 3) Child Abuse 4) Dependent Adult/Elder Abuse
Information disclosed during the course of your treatment may also be communicated in other special circumstances. Your case may also be discussed with a clinical supervisor. All clinical activity is conducted by licensed professionals or supervised by individual licensed to practice in the State of California. All clinical supervisors operate under the same professional guidelines and are legally bound to keep the information confidential.
I have read the above and understand that the therapy relationship is private and confidential one with the exceptions noted above.
STATEMENT-CONFIDENTIALITY OF SUBSTANCE USE DISORDER PATIENT RECORDS AND CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
The confidentiality of substance use disorder records maintained by KCS is protected by Federal Law and regulations. KCS may not inform a person outside KCS that a participant attends KCS, or disclose any information identifying a participant as having a substance use disorder unless: (1) The participant consents in writing, (2) The disclosure is allowed by a court order, or (3) The disclosure is made to a medical personnel in a medical emergency, or to qualified personnel for research, audit or program evaluation. Violation of Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal Law and Regulations do not protect any information about suspected child abuse or neglect, suspected elderly abuse or neglect and will be reported to State or local authorities. Federal law and regulations do not protect any information about a crime committed by a participant, either at KCS or against any person who works for KCS or any threat to commit such a crime.