In order to consent to treatment for mental health concerns, you need to know the following:

Informed Consent. You have the right to make an informed decision about entering into treatment. Your therapist's explanation of the treatment plan, & this form, & one of our brochures, “Helping You Find Your Strength and Serenity,” or “Preparation for AODA Counseling at Shorehaven,” give you details for your INFORMED CONSENT FOR TREATMENT.

Patient’s Rights. Please read the Wisconsin statement of patient's rights on the other side. Shorehaven clients have the right to request a consultation with the Executive Director or a Consultant. The best care is provided by a team including the therapist and a Certified Supervisor, Psychiatrist, or Consulting Psychologist. So Shorehaven staff will usually consult, as required by law, regarding the best treatment plan for my care.

Consent to Treatment. My signature below indicates my consent to the treatment plan described to me. This consent applies to all providers at Shorehaven who may provide services to me and permits the sharing of information by my providers at Shorehaven. I understand that consent expires at the end of treatment and I have the right to withdraw this consent at any time I choose. I understand this consent is for treatment and does not include participation in research. In case of an emergency, SBH reserves the right to administer medical treatment on the premises.

I have been informed of the following information on the date indicated below.

• Type of treatment to be provided and the expected Goals or Benefits of the treatment.
• Estimated Frequency and Duration of the treatment, and any alternative treatments available.
• Possible Risks associated with the treatment, if any, and possible risks from not receiving this care.
• Estimated Cost of treatment & my ultimate responsibility for costs.
• The Provider of treatment and his or her credentials, and procedures to follow in an Emergency.
• My right to a second opinion. (You will be assisted in obtaining a second opinion.)
• My therapist's supervisor who is available if I have a question/complaint.
• My right to consult with a Psychologist or Psychiatrist

Hours of Operation. SBH is open Monday through Thursday 9:00AM to 9:00PM, Friday 9:00AM to 5:00PM. Counselors may see clients before 9:00AM. or on weekends. Day Treatment groups run from 10:00AM to 1:00PM or from 12:00PM to 3:00PM..

Limits to Confidentiality. The information given in therapy is confidential and will only be released to others with your written permission (or with the permission of a parent or guardian of a minor). Disclosures. However, under Wisconsin & Federal Statutes, confidentiality has limits. I acknowledge these limitations. The therapist may use information within SBH and with its business associates for treatment, payment, and other health care operations. The therapist is usually required to consult with clinical supervisors in order to provide a high quality of care, to answer certain subpoenas or court orders, to report threats of homicide or suicide, to report the suspicion of child abuse or child neglect, and may report elder abuse or abuse of a handicapped person or a crime which may occur in the future. The therapist may report physical assaults or crimes which occur on the clinic premises. Child welfare agencies are considered agents of the Children’s Court and may request our office notes if a child is in Safety Services or protective services. All disclosures will be made to the appropriate parties, such as authorities, parents, or intended victims of violence.

When the therapist must release information without your consent, the information revealed will be limited to what is necessary to protect you or to protect others, or the limited information necessary for collection of a past due bill, or the information ordered to be released to the court. When information is released with your consent, we will release the information you request us to disclose. Certain information is Privileged; your therapist can explain.




(Yes) (No) Shorehaven may send appointment reminders and other correspondence regarding appointments and services.
• Shorehaven may call me regarding appointments, confirmation, etc. We may leave messages with persons you designate
(any restrictions:)__________________________________________________________________
This consent applies continuously throughout my services unless revoked in writing.

The client is aware of the limits to confidentiality, client’s rights, the treatment plan, the payment plan. A copy of the PAYMENT PLAN FORM AND CONSENT FORM HANDOUT, which is the text of this Consent, was given to the client.

These rights apply to inpatient and involuntary patients as well as outpatients. Many of the rights, therefore, may not be completely relevant to your outpatient therapy experience.

Treatment: * To receive prompt and adequate treatment. * To have conditions placed upon you that are the least restrictive of your freedom (except patients under ss. 51.35, 51.37, 971, 975). * To refuse treatment and medications before commitment or because of religious prohibition, and, if you are a voluntary patient, to refuse any treatment. * To be free from unnecessary or excessive medication at any time and to refuse drastic treatment or experimental research. * To be free from isolation and restraint except as a part of a treatment program or in emergencies when you pose a danger to others or yourself.

Access to Courts: * To be considered legally competent, unless otherwise determined by a court, to make your own decisions -- such as marriage, voting, and making a will. (Sec. 51.59 Statutes). * To bring legal action for damages against those who violate your rights.

Privacy Rights: * To refuse to be filmed or taped without your consent (except in maximum security units where cameras monitor common areas). * To pursue the religious worship of your choice. * To have your treatment records and conversations about your treatment kept confidential except as provided by law (Sec. 51.30, Statutes). * To have access to your treatment record after discharge (or during treatment if the facility director approves it) and to have access at all times to records of medications you take or treatment you receive for physical health reasons.

Right to Complain: * If you feel your rights have been violated, you have the right to use a grievance procedure. Contact your Complaint Investigator to file a complaint or learn more about the grievance procedure. Grievance Officer for Shorehaven: Don D. Rosenberg, 3900 W. Brown Deer Rd., Suite 200, Brown Deer, WI 53209, 414-540 2170 X234. If you are dissatisfied with the resolution of your Grievance, you will be advised on taking a grievance to the Department of Health and Family Services.