OMHS, LLC has a grievance procedure which your therapist will discuss with you. You will also be given a brochure outlining the clinic grievance procedure and the options available to you to file a grievance with the state of Wisconsin. OMHS, LLC maintains 2 emergency numbers to be used for consumers who are experiencing a mental health emergency. They are 608-577-3299 and 608-719-8515. These numbers are also available on the clinic telephone messages. OMHS, LLC maintains a policy for the involuntary discharge of consumers. This policy will be given to you at the time of admission for treatment. Oregon Mental Health Services, LLC is required to obtain your consent for treatment. Your signature below indicates that you are giving consent to participate in psychotherapy and that you understand the information presented above. You have the right to withdraw informed consent at any time in writing. This consent will be valid for one year. I have read the above information and have been notified of my rights and the grievance procedure. I have received a copy of OMHS Client Rights brochure (____) and the policy for Discharge from treatment (____). I give my consent to receive psychotherapy treatment. I give my permission to correspond with OMHS electronically (email). (_____) Signature_______________________________________Date___________________ Please print name_______________________________________________________ 05/16
OMHS, LLC has a grievance procedure which your therapist will discuss with you. You will also be given a brochure outlining the clinic grievance procedure and the options available to you to file a grievance with the state of Wisconsin. OMHS, LLC maintains 2 emergency numbers to be used for consumers who are experiencing a mental health emergency. They are 608-577-3299 and 608-719-8515. These numbers are also available on the clinic telephone messages. OMHS, LLC maintains a policy for the involuntary discharge of consumers. This policy will be given to you at the time of admission for treatment. Oregon Mental Health Services, LLC is required to obtain your consent for treatment. Your signature below indicates that you are giving consent to participate in psychotherapy and that you understand the information presented above. You have the right to withdraw informed consent at any time in writing. This consent will be valid for one year. I have read the above information and have been notified of my rights and the grievance procedure. I have received a copy of OMHS Client Rights brochure (____) and the policy for Discharge from treatment (____). I give my consent to receive psychotherapy treatment. I give my permission to correspond with OMHS electronically (email). (_____) Signature_______________________________________Date___________________ Please print name_______________________________________________________ 05/16
Client-Rights-and-Informed-Consent-May-2016.docx