Mental Health and Counseling Consent Forms
Scroll the page to view and read all consent agreements or jump to a consent using these links:
- Authorization for Email Correspondence
- No Show & Cancellation Policy for Psychiatric Services
- Psychiatry Resident Treatment
The Counseling Services consent forms are PDFs and open in a new window:
Informed Consent for Counseling Services
Consent for Counseling Telehealth Services
Authorization to use or disclose protected health information for email communications
Sindecuse Health Center provides a secure patient portal (healthmanager.wmich.edu) as the preferred method for communication with your provider. Unlike conventional e-mail, all HealthManager messaging is done while you are securely logged on to our website. Communicating through HealthManager can help mitigate risks associated with email communication.
1. Patients who want to communicate with their health care providers by email should consider all the following issues BEFORE signing the Authorization to Use or Disclose Protected Health Information for Email Communications:
a. Information transmitted over unsecured wireless and data networks may be viewed by others.
b. Email at Western Michigan University and in general may be forwarded, intercepted, printed, and stored by others.
c. Not all Sindecuse Health Center providers utilize email for purposes of clinical communication.
d. Email communication is a convenience and not appropriate for emergencies or time-sensitive issues. Questions or concerns sent through our secure patient portal receive priority and are routinely reviewed. Responses to email communication may vary depending on provider schedules. Please call if you do not receive a timely response.
e. Employers generally have the right to access any email their employees receive or send using employer-owned email addresses or systems.
f. Individuals, other than the health care provider, may read and process email as part of your continued care.
g. Clinically relevant messages and responses will be documented in the medical record.
h. Communication guidelines must be defined between the provider and the patient, including, (1) how often email will be checked, (2) instructions for when and how to escalate to phone calls and office visits, and (3) types of transactions that are appropriate for email.
i. The body of the email message must include clear patient identification including patient name and date of birth and a telephone number where the provider can reach the patient.
j. Western Michigan University will not be liable for information lost or misdirected due to technical errors or failures.
2. The following confidentiality statement is recommended for inclusion in all emails between patients and providers:
a. NOTE: This communication may contain information that is legally protected from unauthorized disclosure. If you are not the intended recipient, please note that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this message in error, you should notify the sender immediately by telephone or by return email and delete this message from your computer.
b. Person(s), class of persons, or organizations:
________________________________________________________________________________
By signing this form, I authorize the following person(s), class of persons, or organization to communicate via email with me, as necessary, for medical care and treatment.
Consent for Treatment
I understand that the following types of protected health information may be used, disclosed, and retained by the health care clinicians because of the email communications:
- My personal health information and my email address.
- Electronic diagnostic images (x-rays, MRIs, CT scans), laboratory test results, pathology reports, and other diagnostic test results.
- Photographs of parts of my body that may include my face.
- Substance Abuse
- Mental Health
I have read and understand the Authorization information sheet and agree that email messages may include protected health information about me, whenever necessary.
I understand that, by federal law, I have read and understand the Authorization information sheet and agree that email messages may include protected health information about me, whenever necessary.
I understand that, by federal law, Western Michigan University may not use or disclose my health Information without my authorization, except as provided in the University's Notice of Privacy Practices.
My signature on this authorization indicates that I am giving permission to my healthcare provider to use and disclose the protected health information described above in email communications to me.
I hereby release Western Michigan University and its employees from any and all liability that may arise from the release of information as I have directed.
I understand that I have the right to revoke this authorization at any time. If I want to revoke this authorization, I must do so in writing and address it to the person or organization named above that I am authorizing to disclose my information. I understand that if I revoke this authorization, it will not apply to any information already released as a result of this authorization.
I understand that, once information is disclosed pursuant to this authorization, it may no longer be protected by the federal medical privacy law and could be disclosed by the person or organization that receives it.
I am aware that if I communicate with my provider via email and not through the Healthmanager patient portal, there is a higher risk of incidental or accidental disclosure of my information. I accept all increased risks of disclosure associated with email communication.
No Show & Cancellation Policy for Psychiatric Services at Sindecuse Health Center
Purpose
Attending regularly scheduled appointments is necessary to provide quality care as demonstrated by the treatment plan. This policy ensures that patients are aware that their psychiatric care may be terminated for non-participation.
Policy
- In the event that a patient does not show for an appointment or cancels an appointment on the same day of the appointment for two (2) consecutive appointments or three (3) appointments within a twelve-month period, the provider may pursue closing the patient’s case.
- When a provider closes a case, the patient will be sent a letter via certified mail notifying the patient that their case will be closed due to their non-participation.
- Services will be provided by the SHC psychiatric provider for a maximum of 30 days from the date the letter is sent.
This policy/procedure will be explained to the patient and patient will have the opportunity to read it. The patient’s signature (below) indicates an understanding of the consequences of non-participation in the treatment plan.
Procedure
- Using the criteria above, when a provider closes a psychiatric patient’s case at the SHC, the provider will send the patient a certified letter. The Counseling Services Administrative Assistant will mail this letter and will document such in the EMR in an encounter note.
- The letter will include:
a. The reason for termination, outlining no show and cancellation history.
b. Information that the patient may receive psychiatric care from the SHC for a maximum of 30 days from the date of the letter.
c. Information regarding other psychiatric healthcare providers/services available.
d. A release of information to forward SHC psychiatric records to the provider of the patient’s choice.
e. A copy of the letter will be scanned into the patient’s EMR.
f. The provider will document appropriately in the patient’s EMR.
g. The certified mail return receipt with the recipient’s signature will be scanned into the EMR.
The above policy/procedure has been explained to me. My signature below signifies my understanding of the policy and the consequences of non-participation in my treatment plan.
Psychiatry Resident Treatment
Consent For Psychiatry Resident Treatment
Your appointment is scheduled with one of our Psychiatry Residents. Our Psychiatry Resident is completing the 4th year of residency and will be supervised by Dr. Ruggiero. Your treatment will transfer to Dr. Ruggiero's schedule for future appointments once the Resident is no longer available.
Consent For Treatment
I have read and understand the above information, and I consent to treatment by Psychiatry Resident.