By signing below, I give consent for my child to receive mental health treatment and supportive services from Cognitive Hygiene Advanced Therapy. These services may include:
Individual or group therapy
Therapeutic behavioral support
Day Treatment programming
Psychosocial and recreational activities
Transportation
Other clinically appropriate interventions
I understand that:
The purpose, benefits, and potential risks of treatment have been explained.
A personalized treatment plan will be created based on my child’s needs.
I will be informed of treatment progress and involved in decision-making according to Ohio law and Medicaid regulations.
All treatment records (notes, plans, assessments) are confidential and may only be reviewed for quality assurance, compliance, or accreditation.
Health information may be shared as needed for treatment, billing, or healthcare operations and will be protected under HIPAA and state confidentiality laws.
I acknowledge that I have received or been offered the Client Rights and Responsibilities, Client Grievance Policy, and Notice of Privacy Practices, and may ask questions at any time. I understand this consent is valid throughout treatment and may be revoked in writing.