Consent for Services

I confirm the following have been offered to me, and I understand I may request a copy at any time, or find the information on the Woodland
Centers website at www.woodlandcenters.com .
- 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 telehealth services)

Telehealth Services: I may be offered services via telehealth which involves the delivery of mental health services by two-way electronic
communication with a provider who is at a different physical location. Prior to scheduling telehealth services, I will have the opportunity
to discuss the risks and benefits. I consent to the use of telehealth if appropriate for my treatment. I understand that I may decline
telehealth services at any time and request to be seen in person. Receiving services via telehealth requires access to a mobile device or
computer with high-speed internet access, and services may be interrupted due to technical issues. I understand that I may not record
telehealth sessions. Woodland Centers will not record telehealth sessions unless I have given consent and signed a Videotaping
Authorization form.
 Integrated Care: If I am or will be working with more than one Woodland Centers program or provider, I give consent to all Woodland
Centers programs and providers involved in my treatment to share my protected health information, including records related to
substance use, in order to facilitate better coordination of services and integration of care.
 Clinical Trainees/Clinical Interns: I acknowledge and consent that a Woodland Centers intern or clinical trainee who is pursuing licensure
or credentialing may provide services under the supervision of a designated licensed supervisor. The licensed supervisor will have access
to my records and may join sessions to observe the intern or trainee. I understand that services provided by an intern or clinical trainee
are billed at the standard rate for such services under the licensed supervisor.
 Parent/Legal Guardian of Minors (ages 15 and under): I attest that I am the parent/guardian of the minor client and have the legal right
to arrange services for the minor client (including substance use program services. I understand that another parent or legal guardian
may have access to the minor client’s records, even if they did not arrange the services. Any disagreement between parents or legal
guardians regarding services for a minor client must be discussed at the first session or as soon as the disagreement arises. If the
disagreement cannot be resolved, Woodland Centers may discontinue services. Our services are focused on treating the presenting
mental health or substance use issues and are not focused on assessing parenting capacity or documenting disputes between parents.
Woodland Centers reserves the right to require documentation of legal custody arrangements at any time.
 Minors age 16 and up: A minor sixteen and older may consent for outpatient mental health or substance use program services without
parent or guardian consent (Minn. Statute §144.3431). When a minor consents for services, an authorization to release protected health
information will be required to share information with parents/guardians. (Parent or guardian consent is required for: Day Treatment,
Crisis Stabilization, and/or Family Community Support Programs)
 Findhelp: Findhelp is a resource platform for clients who identify needs based on Social Determinants of Health (SDOH) screening,
including transportation, food, housing, etc. Client information will be entered onto the Findhelp platform to connect to appropriate local
resources in the community. If I do not want information shared with Findhelp, I must notify my care coordinator in writing.
 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. I understand that
standard rates for calls or texts may apply.
 Emergencies: Some providers and services may not be available after hours or in an emergency. You should discuss a plan with your
provider for how to address mental health emergencies, including how to access crisis services. If you or someone else is experiencing a
mental health emergency you can call Mobile Crisis Response, call the Suicide Crisis Lifeline by dialing 988, or go to the nearest
Emergency Department.