I (we) hereby give my (our consent to The Potter’s House Family and Children Treatment Center to provide treatment for me (us) and/or for my minor child(ren) on an outpatient basis. The risks and benefits of treatment have been explained to me (us). I (we) also understand that clinical records may be reviewed by a Quality Assurance Committee and/or in clinical supervision to ensure quality treatment for my (our) family. Information necessary to carry out treatment, payment and healthcare operations will be submitted to appropriate organizations for accreditation, certification or authorizations. The Potter’s House Family and Children Treatment Center Client Grievance Procedures, Client Rights and Responsibilities and Notice of Privacy Practices have been explained to me and I have received my own copy. If our Privacy Practices should change, you will be notified of the change by receipt of the new Notice of Privacy Practices. The new Notice of Privacy Practices will also be posted.
To provide treatment to minors, The Potter’s House Family and Children Treatment Center is required to obtain consent for treatment from the minor’s legal guardian or custodian. By signing below, you are attesting that you are legally responsible for the minor named below.
You have the right to refuse treatment. If you refuse treatment, The Potter’s House Family and Children Treatment Center staff will, with your approval, offer assistance in developing alternative approaches to ensure you and/or your minor child (ren) receive the needed or recommended services. If you refuse treatment, please see The Potter's House administrative staff.
You have the right to withdraw consent for treatment at any time. If you choose to withdraw consent, The Potter’s House Family and Children Treatment Center staff will explain any implications or potential consequences for refusing treatment. If you have chosen to withdraw consent for treatment, please see The Potter's House administrative staff.
I hereby acknowledge that I have received and have been given an opportunity to read a copy of the HIPAA Notice of Privacy Practices.
I understand that if I have any questions regarding the Notice or my Privacy Rights, I can contact The Potter’s House Family and Children Treatment Center at (678) 330-1400 or the Regional Office for the Department of Health and Human Services (DHR).
In case of an emergency and the parent(s)/guardian(s) cannot be reached, please contact one of the following persons:
In case of an accident or illness requiring medical attention, the undersigned authorize The Potter’s House Family and Children Treatment Center to call a health provider or take my child to the nearest hospital or doctor, and it is understood that if possible, their services will be obtained. If neither parents nor preferred care provider can be contacted, The Potter’s House Family and Children Treatment Center is authorized to contact another health care provider. It is also understood that this agreement covers only those situations, which in the best judgment of The Potter’s House Family and Children Treatment Center are true emergencies.
It is the policy of Department of Behavioral Health and Developmental Disabilities that an individual must have a verified diagnosis within the first 30 days of intake in order to continue to meet the diagnostic criteria and continue services.
A no-show is defined as failure to keep your appointments without prior notification. If you cannot attend your appointment you are expected to contact your therapist or the Administration staff 24 hours prior to your appointment. Calling a few minutes prior to your session will be deemed as a no-show. The Potters House Family and Children Treatment Center will charge a No-show/Cancelation fee in the amount of $ 25. To prevent from being charge this fee, all appointments must be confirmed 24 hours in advanced. Please know that we do understand that emergencies will occur; however, we expect you to call 24 hours prior to your scheduled appointment to avoid a no-show infraction and a no-show fee. Also, please understand the importance of complying with all appointments as they have a vital effect on your family quality and continuity of service
The Potter’s House Family and Children Treatment Center will take the following actions for no-shows:
I.Mission and Philosophy of The Potters House
II.Hours of Operations
VI.Behavioral Assessment/Individual Resiliency Plan
VIII.Transfer and Re-Entry
X. Client Satisfaction
XI. Consumer Rights
XIII.Code of Ethics
XVIII.Drug Use Policy
XIX.Grievance and Appeal Procedures
By signing below, I attests that I am legally responsible for the minor named (if applicable) and that I have read and fully understand and acknowledge receipt of Labwork Policy, Prescription Policy, Consumer Bill of Rights, Consumer Grievance, Service Requirements, No-Show Policy and Diagnostic Assessment Contract, policies as a participant in The Potter’s House Family & Children Treatment Center.I understand that if at any time I have questions about any of the sections, I may request to speak to a representative of The Potters House.