Treatment Consent

I hereby consent to ARK in partnership with CHOICES Behavioral Health Care to provide treatment for myself/my child on an outpatient and/or residential basis. The risks and benefits of treatment have been explained. I understand that clinical records may be reviewed by a Quality Assurance Committee and/or in clinical supervision to ensure quality treatment.

Information necessary to carry out treatment, payment and healthcare operations will be submitted to appropriate organizations for accreditation, certification and authorizations.

Cost Sharing Fee Agreement

I understand that there are charges for various Shark Tank Youth Club program fees in partnership with CHOICES Behavioral Health Care services. I will provide necessary information to determine my eligibility for insurance plans, Medicaid, or Self Pay based on a sliding fee scale calibrated to my ability to pay.

Telehealth Consent

Telehealth allows my therapist to diagnose, consult, treat and educate using interactive audio, video or data communication. I understand my rights under this agreement including:

• Right to confidentiality under the same laws as in-person counseling
• Understanding of mandatory reporting exceptions
• Awareness of potential technical risks and interruptions
• Right to withdraw consent with written notification