Each staff member makes every effort to safeguard the legal and civil rights of each client at all times regarding the treatment process and discharge from the treatment process. As a client of Norwood Behavioral Health, you have the right to:
Know about our professional qualifications.
Know about and comment on the agency's policies and procedures.
See and discuss our fee scale.
See and comment orally and/or in writing on the record kept of your contact with this agency and insert your own statement if you wish.
Discuss any concerns with your clinician, and if you desire, have a three-way conference including you, your clinician, and their supervisor.
Make suggestions as to how our policies and services can be improved.
You have the right to refuse any services offered.
All services rendered while you are in treatment at Norwood Behavioral Health are held in strict confidence. Our policies and procedures protect your privacy to the fullest extent of the law. Since your discussions with staff are confidential, the agency ordinarily will not disclose information about you and to anyone else without your written permission. Similarly, the agency cannot request information about your from others without your written permission. Under the law, there are some exceptions to the normal protection of your privacy. For example the agency must disclose the information it considers necessary in order to protect someone’s life or when a specific law requires disclosure. Similarly, a court order waves confidentiality.
I have reviewed the above. I give CONSENT for TREATMENT and understand I have the right to revoke this consent at any time.
I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Norwood Behavioral Health or my insurance company to release any information requeired to process my claims.
MISSED APPOINTMENT POLICY
By signing below, you are indicating you agree to and understand that all appointments must be cancelled within 24-hours. You may contact your provider via email or phone. All missed appointments may result in a fee of $75 for therapy sessions or $100 for psychiatry sessions.
By signing below, you understand the first visit at our practice is 60-minute intake appointment. After this evaluation, if the clinician feels our practice is not suitable for your needs, we will help to facilitate a referral to an appropriate facility.