Be accepted for psychiatric, mental health, or alcohol and drug abuse treatment as described to me.



1. I give my authorization and consent to receive outpatient diagnostic and treatment services.

2. I have been given information regarding my rights and responsibilities as a participant.

3. I have been given information regarding the limits of confidentiality of my records.

4. I have been given information regarding the cost of services.

5. I am freely choosing to enter into treatment, and I understand that I may discontinue treatment at any time.

6. I have been given information about the advantages and disadvantages of the treatment recommended as well as other alternatives.