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Practice Policies

Combined Consents and Policies for HRSA Compliance (Web)

Consent to Treatment of Behavioral Health and Substance Use Services

Consent to Treatment of Behavioral Health and Substance Use Services

I understand that during treatment, I may need to discuss material of an upsetting nature to resolve problems. While I understand that treatment is not guaranteed to resolve all issues, I consent to actively participate in developing and implementing my individualized treatment plan.

Compliance with Treatment Plan:

I agree to consistent attendance and understand that frequent "no-shows" or late cancellations may result in termination of services or fees assessed to my account.
I am responsible for adhering to my prescribed treatment plan, and failure to do so may lead to discharge from services.

West Valley Health Equity has provided me with a copy of their clinic policies. I understand that I am responsible for reviewing these policies and fulfilling all care, financial, and administrative requirements.

By signing this agreement, I consent to receive behavioral health services, including medication management and/or psychotherapy. I understand that it is my responsibility to read the policies carefully and refer to them when needed.

Patient Information:

First Name

Last Name

Date of Birth

Signature

Date

Crisis Policy

West Valley Health Equity is an outpatient behavioral health office and does not provide emergency services. If you are experiencing a mental health or physical crisis, please use the resources below:

988: Call or text for mental health and substance use-related crises.
Mind 24/7: Call 844-646-3247 for 24/7 in-patient and outpatient services.
Urgent Psychiatric Care Center (UPC): 602-416-7600, 1201 S. 7th Ave., Phoenix, AZ 85007.
Banner Behavioral Health (Scottsdale): (480) 448-7500, 7575 E Earll Dr, Scottsdale, AZ 85251.
Quail Run Behavioral Health: 844-772-7771, 2545 W Quail Ave., Phoenix, AZ 85027.
Central Arizona Crisis Line: 602-222-9444.
Central Arizona Warm Line: 602-347-1100.
Northern Arizona Crisis Line: 1-877-756-4090.
For emergencies, dial 911 or visit the nearest emergency room.

Patient Information:

First Name

Last Name

Date of Birth

Signature

Date

Controlled Medications Policy

Due to the risks associated with controlled substances, the following policy must be adhered to:

Random Drug Screens: Agree to complete drug screens within 24 hours when requested.
Monthly Appointments: Controlled substances require monthly visits unless otherwise specified by your provider.
Single Provider Policy: Do not seek controlled medications from other providers or pharmacies.
No Early Refills: Manage your medication supply to align with scheduled appointments.
Electronic Prescriptions: Prescriptions will be electronically sent to your chosen pharmacy.
Monitoring: Prescription tracking systems are used to ensure compliance.
Efforts to Reduce Use: Work toward reducing reliance on controlled substances by engaging in alternative therapies such as Cognitive Behavioral Therapy (CBT) or biofeedback.
Withdrawal Management: Seek emergency care for withdrawal symptoms, as West Valley Health Equity cannot provide immediate crisis services.

By signing this agreement, I acknowledge that I have read and understood the policy. I accept full responsibility for adhering to the guidelines outlined above.

Patient Information:

First Name

Last Name

Date of Birth

Signature

Date

Consent for Telehealth Consultation

I understand that my health care provider will use telehealth technology to conduct consultations. While this allows for convenient access to care, I acknowledge the following:

Telehealth is not for emergencies. In emergencies, I will call 911.
The telehealth platform facilitates video conferencing but does not provide medical advice or care.
Technical difficulties may occur, and either party may discontinue the session if the connection is inadequate.
Confidentiality: I will not share my telehealth appointment link with unauthorized individuals.

I have had the opportunity to ask questions about telehealth services and understand the risks, benefits, and alternatives.

By signing this form, I agree to participate in telehealth consultations and abide by the terms outlined.

Patient Information:

First Name

Last Name

Date of Birth

Signature

Date

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Consent to Treatment of Behavioral Health and Substance Use Services