Bismillahir Rahmaanir Raheem

MYPI Wellness House

CONSENT FOR REFERRAL/TREATMENT POLICY

I consent to receive a mental health evaluation and referral for treatment services at MYPI Wellness House. By completing this form, I am indicating that:

  • I have read and understood this Consent for Treatment.
  • Any questions which I may have had regarding this form have been answered to my satisfaction; and,
  • I agree to the following:
Treatment Acknowledgments:
  1. The services which I receive will be provided by the Trusted Providers of MYPI Wellness House.
  2. MYPI Wellness House has made no promise or guarantee that a specific outcome would result from these services.
  3. I voluntarily enter treatment; I can choose to discontinue treatment at any time unless an emergency commitment has been placed on me or a petition for my involuntary commitment to substance abuse treatment has been filed in an appropriate court. If I request termination from therapy, and am eligible for termination, the provider will process my request and terminate me as soon as they reasonably can. Processing my request may take several hours, however, depending upon staff workload and other events taking place that require staff attention.
Fees and Refunds:
  1. MYPI Wellness House does not charge any fees directly to clients. Instead, we pay our contracted providers at set rates. As part of their Trusted Providers agreement, providers do not collect any fees from Medicaid clients. For individuals with insurance, they will only be responsible for the copay rate, and MYPI Wellness House will cover the remaining balance to the provider.
    This arrangement ensures that clients are not financially burdened, and MYPI Wellness House facilitates payment to the providers on behalf of the clients. Detailed fee information can be found in the separate Fee Disclosure form. Any eligible refund of fees will be issued by check and requires a minimum processing time of ten business days from the date of the refund request. Cash refunds will not be provided under any circumstances. Refunds will only be issued to the individual who originally paid the fees.
Medication Disclosure:
  1. The treatment program I am entering is conducted in a drug free environment. I will inform staff about all medications, both prescription and over the counter, which I am currently taking.
Client Rights and Responsibilities:
  1. Copies of the Client Rights and Responsibilities, facility, maintenance, and safety contact information, 42 CFR part 2, HIPAA, the Client Grievance Procedure, notice of privacy rights and the rules for the program in which I am being enrolled have been made available to me. I understand that it is my responsibility to read these documents and ask questions if I do not understand anything that they contain.
Discharge and Follow-Up:
  1. I have the right to request discharge from therapy, and if eligible, the staff will process my request promptly. Processing time may vary depending on staff workload and other events requiring staff attention.
  2. MYPI Wellness House may refer me to other therapists or mental health providers for additional therapy services, for which I am financially responsible.
  3. Following my discharge from therapy, MYPI Wellness House may contact me to ensure its therapy services meet my needs.
  4. I voluntarily enter treatment; I can choose to discontinue treatment at any time unless an emergency commitment has been placed on me or a petition for my involuntary commitment to substance abuse treatment has been filed in an appropriate court. If I request discharge from the program, and am eligible for discharge, staff will process my request and discharge me as soon as they reasonably can. Processing my request may take several hours, however, depending upon staff workload and other events taking place that require staff attention.
Acknowledgement:
  1. I acknowledge that I am consenting to therapy facilitated by MYPI Wellness House and agree to the payment terms. I confirm that I have received copies of my rights and responsibilities as a client, as well as the HIPAA and 42 CFR Part 2 Notice of privacy rights and confidentiality. For complaints related to 42 CFR Part 2, please contact the U.S. Attorney's office at: 402 Rood Ave, Grand Junction, CO 81501 ยท (970) 241-3843
  2. I understand that it is my responsibility to read these documents and ask questions if I do not understand anything that they contain.
  3. I acknowledge that I am consenting to treatment at MYPI Wellness House, I agree to the payment terms, I acknowledge that I have received a copy of; my rights as a client and (HIPAA and 42 C.F.R Part 2) Notice of privacy rights and confidentiality.