Consent for Services

I confirm the following have been offered to me:
-Notice of Privacy Practices (Uses and Disclosures of Protected Health Information, Privacy Practices and How to file a complaint)
-Client’s Rights and Responsibilities
-Fee and Payment Information (including Sliding Fee Schedule)
-Electronic Communication (including e-mail, text, and Tele-Health services)
I understand I may request a copy at any time, or find the information on the Woodland Centers website at www.woodlandcenters.com.

-Tele-Health Services: I may be offered mental health/substance use program services, via Tele-Health systems that involve the delivery of these services by electronic communication with a provider who is at a different physical location. Prior to scheduling Tele-Health services, I will have the opportunity to discuss the risks and benefits. I consent to these services if appropriate to my treatment with the knowledge that I may decline Tele-Health services at any time. This service is
dependent on insurance approval.

- Clinical Trainees/Clinical Interns: I acknowledge and consent that I or my child may be treated by a Woodland Centers clinical trainee who is pursuing licensure or credentialing. Services in this case will be provided under the clinical supervision
of a designated licensed supervisor. The supervising clinician will have access to my records and may join sessions for observation of the intern or trainee. I understand that services are billed at the same rate under the licensed provider/supervisor.

- Parent/Legal Guardian of Minors: I am the parent/guardian of the client and have the legal right to arrange services for the client. (PLEASE NOTE: the other parent with legal rights will have access to the child’s information.) If there is a disagreement between parents regarding services, this must be discussed at the first session. If an agreement for treatment cannot be arranged, Woodland Centers may discontinue services. Our services billed as mental health services are focused on treating the presenting mental or substance use issues and not focused on assessing parenting capacity or documenting disputes between parents. Woodland Centers reserves the right to require documentation of legal arrangements at any time.

- Text/E-Mail Communication: By providing a cell phone number and/or email address, I am consenting to receiving communications including but not limited to voice message calls, text messages, and emails from Woodland Centers employees. Standard rates for calls or texts may apply.