Informed Consent

Treatment

I give permission to Minnesota Mental Health Clinics (MMHC) to evaluate, administer, provide diagnostic testing, prescribe medication, develop a treatment plan, and provide treatment with my participation. I understand that the practice of medicine and psychotherapy is not an exact science, and I acknowledge that no guarantees have been made to me as the result of assessment or treatment in this facility.

Minor Consent

For mental health services, minors who are 16 years of age and older can consent to inpatient or outpatient mental health services without the approval of the parent/legal guardian. In situations where the parents are not legally married, we require consent from both parents before the minor can be seen for services. As a parent/legal guardian, I understand that my child’s right to withdraw from services will be respected without explanation.

Consent for Telehealth

Mental health care services are available by two-way interactive video communications and/or by the electronic transmission of information at Minnesota Mental Health Clinics. Referred to as “telemedicine” or “telehealth,” this means that I will be evaluated and treated by a mental health care provider or specialist from a different location. I understand and agree to the following:

1. The mental health care provider will be at a different location from me. I will be connecting to remote services from a location in the state of Minnesota that is private and comfortable to me.
2. I will identify and sign a release of information form for an Emergency Contact (EC) who will be available to me in relatively close physical proximity during all telehealth sessions in case of an emergency. I will provide the contact information for this person to my mental health provider, as well as the information for local emergency services.
3. I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, the consultant and presenting practitioner. I will give my verbal permission prior to additional personnel being present. I will inform my mental health care provider if someone is attending the session with me or if there are other people in the room where I am receiving telehealth services.
4. I have the option to test out the telehealth technology prior to my first telehealth session with my provider. I will be provided with the appropriate connection instructions. My provider will be able to assist me with setting up a separate appointment to learn how to use the technology.

I understand that my participation in “telemedicine” or “telehealth” is voluntary and constitutes a waiver of the usual right to provider-client privacy and may possibly increase the risk of disclosure of my personal data.

I further understand that I have the right to:

1. Refuse the telehealth session or stop participation in the telehealth session at any time.
2. Request that the presenting practitioner refrain from transmitting my information if I make the request before the information is transmitted.

Consent for Personnel in Training

I am aware that clients at this facility may be attended to by medical, nursing, and/or other mental health care personnel in training, who may be present during client care as part of their education.