Thank You

Practice Policies

Combined Consents and Policies for HRSA Compliance (Web)

Consent to Treatment
Consent to Treatment (Cont)
HIPAA Notice of Privacy Practices
Patient Rights and Responsibilities
Practice Policies

0% Complete

1 of 5

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

Clear

Date

If you are human, leave this field blank.

For MAT & behavioral health services, please call or text (480) 487-2307

For housing information, please call or text (602) 879-3392

Consent to Treatment of Behavioral Health and Substance Use Services