BCFS Health and Human Services

Informed Consent 

CONFIDENTIALITY
The privacy and confidentiality of our sessions are extremely important to BCFS HHS. Statements provided below should be viewed as an extension of the information provided in the Notice of BCFS Practices to Protect the Privacy of Your Health Information and the Professional Services Acknowledgment Form.

BCFS HHS client information is entered into a secure database for data collection purposes and is monitored by funding or oversight agencies. BCFS HHS service providers have access to the same documentation system containing client information however, each provider holds an ethical obligation to refrain from viewing any unassigned client information without client’s permission.

Consent for media release, transportation, releases of liability and information maybe revoked in writing by the person who gave authorization. If not earlier revoked, this consent shall terminate in one year from the above date without written notice.

       Please initial below the checked box indicating your preference for each consent/release item listed.

1. COMPLAINTS
If you have any complaints or questions, please contact the office Director, Jeff Wolpers at (956) 230-3849. You may also submit a grievance form provided by BCFS HHS.
2. OFFICE POLICIES
BCFS HHS requests the courtesy of a 24-hour advance notice of cancellation of an appointment, if you are unable to attend. After 30 days if you have been unable to contact and/or not attended scheduled appointments, your case will be closed. If you return within 90 days of case closure your services will be resumed.
3. HOURS OF OPERATION AND EMERGENCIES
8:00AM – 5:00PM
Office Phone Number: (956) 230-3849

Parent Educators at BCFS HHS are not crisis counselors. The Parent Educator is not available for immediate client emergencies or crises. If in a crisis and need help immediately, please proceed to your nearest emergency hospital for evaluation or dial 911 or contact the Director, Jeff Wolpers at (956) 230-3849.

National Suicide Prevention Hotline     1 (800)273- TALK (8255)
Texas Runaway Hotline                         1 (888) 850- HELP (4357)
Information and Referral                        2-1-1
Texas Foster Youth Justice Project       1 (877) 313-3688

In addition, your assigned Parent Educator may not work weekends, from time to time will take vacations, or may be absent due to training, family emergencies, etc. Due to the nature of the job, your assigned Parent Educator is not always available and therefore another staff member for the HOPES program will assist. For any emergency issues please utilize the hotline.

In the event that your Parent Educator becomes incapacitated and cannot practice, all client files and records will be stored with and can be accessed by the remaining BCFS HHS Parent Educator or other authorized BCFS HHS staff. All client files and records of any BCFS HHS Parent Educator, are the responsibility of BCFS HHS.

Your signature below means that you have read and agree to participate in counseling voluntarily, without force. Furthermore, your signature means that you understand all of the information in this document and hold harmless all entities for legal, financial, and/or other compensation for results which do not meet you or your family members’ stated expectations for therapy.

I have read, understand, and have been advised by a HOPES representative concerning the contents of this document. I hereby grant my permission for all services list above.

Signature of adult requesting services:

By signing as a witness, I am stating that I have reviewed all pertinent information regarding consent to services, with the client/guardian, as required by BCFS HHS.