Consent for Treatment Services

  1. I understand and agree to the information presented and provided to me in the New Directions Individual Orientation Information Packet and terms of behavioral health services and consent to receiving services at NEW DIRECTIONS NORTHWEST, Inc. I feel that I have been oriented to the services provided and understand my rights as an individual receiving these services.
  2. I agree to pay the necessary fees and provide third party assignment at the time of service.
  3. I understand that, should I have no insurance coverage and need to pay for services on my own, that I may be eligible for a discounted fee based on my gross household income that could significantly alter the cost of my services.
  4. I understand that should my coverage/benefits change prior to completion of treatment, I will be required to provide the new benefit information and/or meet with the financial office to make other payment arrangements at that time.
  5. I understand that I am responsible for canceling all appointments at least twenty-four (24) hours in advance and that I may not be able to see my counselor if I am more than fifteen (15) minutes late for my appointment.
  6. I understand that I may be required by my insurance to make a co-payment and that this payment is due at the time services are rendered. I understand that I am ultimately responsible for any charges incurred on this account.
  7. I agree to pay all charges not paid by insurance or any other payer source. If legal proceedings are required to collect this account, I agree to pay all collection costs including reasonable attorney fees and court costs.
  8. I also understand that I may be charged at the individual services rate for additional services such as consultation or case management as indicated in my treatment plan.
  9. I also understand that should I request a copy of my records, I may be charged $1.00 per page requested and I agree to pay this in full.
  10. I consent to admission/participation in New Directions Northwest (NDN) treatment programs. I agree to cooperate with evaluation, treatment and continuing care. I will keep NDN informed of changes in my life, such as, change of address, marital status, employment, etc. The fee structure has been explained to me.
  11. NDN will promise treatment as requested and agrees to provide information to me on my progress.
  12. When this agreement regards a minor, I agree that NDN may authorize emergency medical care in the event of an emergency.
  13. I have been orientated to the agency, programs and my rights.