Consent for Psychiatrist Rehabilitation Services

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Section 1: Service Type Selection

Please select the specific type of rehabilitation services you will be receiving with our clinic.

Full Name

Service Type

Section 2: Program Consent & Patient Rights

Please read each statement carefully and check the corresponding boxes to acknowledge your rights and your agreement to the terms of your care.

Program Agreement

I agree to participate with and through Jay Care Mental Health Center.

I understand that this rehabilitation intervention will be for my psychiatric and/or emotional services.

Right to Fair Treatment

I understand that I have the right to ethical and fair rehabilitation services given without regard to my race, religion, ethic origin, sexual orientation or color.

Right to Appeal

I understand that I have the right to appeal any decision made in my rehabilitation by first discussing it with my primary rehabilitation coordinator.

I understand that if I am not satisfied with the determination of this appeal I may then appeal to the program director or the Behavioral Health System Baltimore.

Right to Refuse

I understand that I may refuse services at any time during the course of rehabilitation services at Jay Care Mental Health Center.

Policy Acknowledgement

I understand that if I choose to refuse services or to rescind this content for rehabilitation services with JCMHC against medical advice, I have been given a copy of Patient Rights Policy, Grievance Process and Discharge Policy for my review.

Section 3: Digital Signature & Authorization

Please provide your digital signature below to confirm your understanding and agreement to the terms outlined above.

Person served / Legal Guardian Signature

Sign Here

Date

Program Director Signature

Sign Here

Date

Consent for Psychiatrist Rehabilitation Services

Home > Forms Hub

Section 1: Service Type Selection

Section 2: Program Consent & Patient Rights

Section 3: Digital Signature & Authorization

8508 Loch Raven Blvd, Towson, MD 21286

info@jaycarementalhealthcenter.com

1 (443) 275-2354

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