PURPOSE OF SERVICES
I consent to receive behavioral health services (e.g., assessment, counseling, psychotherapy, case management) from a licensed provider. These services aim to improve my mental, emotional, and social well-being.
POTENTIAL BENEFITS AND RISKS
Benefits may include improved coping, symptom relief, and better overall functioning. Risks may consist of temporary emotional discomfort, increased distress, or changes in relationships.
CONFIDENTIALITY
My behavioral health information is protected by HIPAA and ND law. Exceptions include:
- Danger to self or others
- Suspected abuse/neglect of a child, elder, or vulnerable adult
- Court orders or legal requirements
- Necessary coordination of care
If receiving any substance use disorder treatments, a separate federal consent may apply (42 CFR Part 2).
TELEHEALTH SERVICES
If you receive services through telehealth (video or phone):
- You have the same rights and confidentiality protections.
- You must be located in North Dakota at the time of your session unless otherwise allowed by your provider's license.
- You may stop telehealth sessions at any time and request in-person services if available.
PATIENT RIGHTS
I understand that I can:
- Ask questions about my care
- Refuse or withdraw from treatment at any time
- Access my records per facility policy
CONSENT TO TREAT
I have read or had this information explained to me. I understand the purpose, benefits, and possible risks of receiving behavioral health services. I have had the opportunity to ask questions and agree to receive services from Northland Health Centers. I understand that I may withdraw this consent at any time.