Client Rights + Consent to Treatment - Brave Health



Client Name: _______________________________________ Date: _________________



Guidelines for acceptance and participation in the program are the same for everyone without regard to race, color, creed, national origin, age, gender, disability, secual orientation, and/or prior treatment history. It is Brave Health’s policy to provide reasonable accommodations to clients with disabilities to ensure their access and opportunity to the same quality and care as other clients without disabilities. 

The following information has been reviewed with me:

  • Condition
  • Services may be provided via telehealth/eServices through use of technology.
  • Proposed interventions, treatment and medications
  • Potential benefits of interventions, treatment and medications,
  • Potential risks of intervention, treatment and medications,
  • Problem related to wellness/recovery
  • Likelihood of success
  • Alternatives to interventions, treatment, and medications
  • Right to refuse interventions, treatment and medications.

I hereby give voluntary consent to Brave Health and/or appropriate authorized staff to provide necessary treatment for my substance abuse, dependency, or mental health and to admit me into the program.

I may revoke my consent for treatment at any time, either verbally or in writing. 

________  Client Initials



As a client of Brave Health services, I understand I have rights to:

      • Response to inquiries within the same business day
      • Access to their records
      • Individual Dignity
      • Nondiscriminatory Services
      • Quality and Competent Services
        • Least Restrictive level of care
        • competent and timely treatment
        • Refuse Treatment
        • be assigned a Primary Counselor
        • Request a change be considered to a treatment member involvement in services if there is a negative impact on the therapeutic relations
        • Participate in treatment planning and decisions
      • Care and Custody of personal effects
      • Education
      • Confidentiality of individual records
      • Counsel
      • Habeas Corpus
      • Liability and Immunity
      • Individual records
      • Privacy consistent with the need for safety
      • Freedom from neglect, physical or psychological abuse, exploitation, humiliation, or any form of corporal punishment
      • Second Opinion of a consultant at the client’s expense
      • File an Advanced Directive
      • File a Grievance

Client who believe that any of these standards have been violated may file a grievance in writing with their therapist and/or any staff member. The staff will respond to the grievance with a proposed resolution within three (3) working days. Additionally, complaints may be filed with the Florida Department of Children and Families. A client will not be penalized in any way for asserting rights or complaining about any misconduct on the part of Brave Health or its staff. 

________  Client Initials



Clients at Brave Health have expectations for their conduct:

      • Read, understand and obey the program rules. 
      • Provide full information regarding any treatment I am receiving or have received including all types of counseling/therapy, medications and/or hospitalization.  
      • Actively participate in the treatment planning and counseling process. 
      •  Attend all activities as agreed upon with staff and indicated on my treatment plan.  
      • Keep scheduled appointments or cancel at least 24 hours in advance.  
      • Pay assessed fees as agreed in a timely manner.  
      • Provide a fluid and/or breath sample for  fluid screening and/or breathalyzer upon request.  
      • Maintain the confidentiality of the program and of other clients at all times. 
      •  Inform staff of any medications being taken. 
      • Refrain from possessing or using weapons with said weapons to be defined by staff.  
      • Refrain from illegal activity. 
      • Refrain from the use of any illicit drugs, alcohol, other substances or medications not approved by staff.  
      • Refrain from sexual involvement with other clients.  
      • Refrain from violent or abusive behavior including physical or verbal threats or acts toward other clients, staff, or property.  
      • Pay for any intentional damages to property that I may cause.  

________  Client Initials



I agree to provide or comply with request made by Brave Health for fluid drug screening and/or breathalyzer screenings.i understand that the results of such screenings will be used in the determination of my treatment needs, Furthermore, I understand that refusal or failure to provide requested sample may result in discharge from the program. 

________  Client Initials



I understand that I will be asked by Brave Health to complete a confidential individual HIV risk screening. I understand that I may be referred to services as appropriate.  Understand that confidential HIV testing is provides per Brave Health policy. 

________  Client Initials



I understand that if I have an advanced directive, I can submit a copy of the document to my therapist to be incorporated into my medical record. If I wish to develop an advanced directive, i can contact any area Hospice program for assistance. 

________  Client Initials




Brave Health continuously works to improve the services and programs being provided. I understand that as part of normal process, Brave Health conducts supervisory quality reviews, risk management reviews, and other quality assurance reviews. I also understand that my data may be gathered and analyzed by Brave Health staff in order to improve services. I understand that any information about me will not be identifiable as my data in any reports or articles published. I understand that reports containing identifiable information about me to any other individual or organization requires my specific written consent.

I am here by restricting the disclosure of any Brave Health reports, reviews, audits which contain my personal identifiable information, other than for licensure or accreditation , unless I provide written authorization. 

________  Client Initials



I understand that Brave Health employees operate under a code of ethical standards. These standards provide guidelines for the client/employee relationship, professional behavior, and the protection of the client welfare. 

I understand Brave Health does not utilize seclusion or restraints (physical or chemical) in its programs. 

________  Client Initials



I hereby give my voluntary consent for treatment. I have received a copy, read and understand the information contained in this document. I agree to abide by the Client Conduct including the drug screen consent and the criteria for involuntary discharge. I understand my client rights and the information pertaining to confidentiality. Further, i understand the section on HIV/AIDS screening and referral.

Client Name:______________________________________     Client ID#: ________________

Client Signature: __________________________________      Date: ____________________

Staff Signature and Credentials: _____________________      Date: ____________________

  • Client is unable to read, I have read these all areas above to the hem/her. 

Staff Signature and Credentials: _____________________      Date: ____________________


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