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Before starting treatment, it is important that you understand your rights as a patient and the policies of this facility. The information can seem lengthy but it is important that you read it carefully so that you fully understand our role, your rights, and your obligation as a patient. Once you read all the policies in this packet please sign and return the forms to the office. You may contact us by phone or mail with questions or comments.

the undersigned, hereby attest that I have voluntarily entered into treatment, or give my consent for the minor or person under my legal guardianship mentioned above, with Austin Center for Psychological Care, PA hereby referred to as ACPC. The rights, risks, and benefits associated with the treatment have been explained to me. I understand that therapy may be discontinued at any time by either party. However, I understand that it is encouraged that this decision be discussed with the therapist. This will help facilitate a more appropriate plan for discharge. By giving consent I am authorizing ACPC to perform the quality care and treatment necessary for my treatment in this facility.

The nature and purpose of the treatment, alternative methods of treatment, and potential risks and complications have been fully explained to me, via meaningful dialogue and question/answer session with the clinician. I acknowledge that the practice of therapy is not an exact science and that no guarantees have been made to me as to the outcome of the treatment. I grant this consent without duress, confusion, or pressure from Austin Center for Psychological Care, PA, and/or their staff, associates, or colleagues.

I consent to treatment and agree to abide by the above-stated policies and agreements with ACPC

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.


This form describes the confidentiality of your medical records, how the information is used, your rights, and how you may obtain this information.

Legal Duties: State and Federal laws require that your medical records are kept private. Such laws require that you are provided with this notice informing you of the privacy of information policies, your rights, and my duties. ACPC is required to abide these policies until replaced or revised. ACPC has the right to revise our privacy policies for all medical records, including records kept before policy changes were made. Any changes in this notice will be made available upon request before changes take place.

The contents of material disclosed to me in an evaluation, intake, or counseling session are covered by the law as private information. ACPC respect the privacy of the information you provide and abides by ethical and legal requirements of confidentiality and privacy of records.

Use of Information: Information about you may be used by associated personnel for diagnosis, treatment planning, treatment, and continuity of care. ACPC may disclose your information to health care providers who provide you with treatment, such as doctors, nurses, mental health professionals, and mental health students and mental health professionals or business associates for purposes such as billing, quality enhancement, training/supervision, audits, and accreditation. Both verbal information and written records about a patient cannot be shared with another party without the written consent of the patient or the patient’s legal guardian or personal representative. It is ACPC’s policy not to release any information about a patient without a signed release of information, except in certain emergency situations or exceptions in which patient information can be disclosed to others without written consent. Some of these situations are noted below, and there may be other provisions provided by legal requirements.

Duty to Warn and Protect: When a patient discloses intentions or a plan to harm another person or persons, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the patient discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the patient. Health records may be released for the public interest and safety for public health activities, judicial and administrative proceedings, law enforcement purposes, serious threats to public safety, essential government functions, military, and when complying with worker’s compensation laws. If a patient states or suggests that he or she is abusing a child or vulnerable adult, or has recently abused a child or vulnerable adult, or a child or vulnerable adult is in danger of abuse, the health care professional is required to report this information to the appropriate social service and/or legal authorities. If a patient is the victim of abuse, neglect, violence, or a crime victim, and their safety appears to be at risk, I may share this information with law enforcement officials to help prevent future occurrences and capture the perpetrator. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. In the event of a patient’s death, the spouse or parents of a deceased patient have a right to access their child’s or spouse’s records.

Professional Misconduct: Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.

Judicial or Administrative Proceedings: Health care professionals are required to release records of patients when a court order has been placed.

Minors/Guardianship: Parents or legal guardians of non-emancipated minor patients have the right to access the patient’s records.

Other Provisions: When payment for services are the responsibility of the patient, or a person who has agreed to providing payment, and payment has not been made in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, progress notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the patient’s credit report may state the amount owed, the time-frame, and the name of the office or collection source.

Information about patients may be disclosed in supervision and/or consultations with other professionals in order to provide the best possible treatment. In such cases the full name of the patient, or any identifying information, is not disclosed. Clinical information about the patient is discussed. In the event in which the mental health professional must telephone the patient for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please notify us in writing where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we do not say the name of the office or the nature of the call, but rather the mental health professionals first name only. If this information is not provided to us, we will adhere to the following procedure when making phone calls: First we will ask to speak to the patient (or guardian) without identifying the name of the office. If the person answering the phone asks for more identifying information we will say that it is a personal call. We will not identify the office (to protect confidentiality). If we reach an answering machine or voice mail we will follow the same guidelines.

Your Rights: You have the right to request to review or receive your medical files. The procedure for obtaining a copy of your medical information is as follows. You may request a copy of your records in writing with an original (not photocopied) signature. If your request is denied, you will receive a written explanation of the denial. Records for non-emancipated minors must be requested by their custodial parents or legal guardians. The charge for this service is $0.10 per page, plus postage. You have the right to cancel a release of information by providing us a written notice. If you desire to have your information sent to a location different than our address on file, you must provide this information in writing. You have the right to restrict which information might be disclosed to others.

However, if I do not agree with these restrictions, ACPC is not bound to abide by them. You have the right to request that information about you be communicated by other means or to another location. This request must be made to ACPC in writing. You have the right to disagree with the medical records in our files. You may request that this information be changed. Although ACPC might deny changing the record, you have the right to make a statement of disagreement, which will be placed in your file. You have the right to know what information in your record has been provided to whom. Please request this in writing. If you desire a written copy of this notice you may obtain it by requesting it from any staff members at ACPC.

Patient Notice of Confidentiality: The confidentiality of patient records maintained by ACPC are protected by Federal and/or State law and regulations. Generally, the therapist may not say to a person outside that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless: 1) the patient consents in writing, 2) the disclosure is allowed by a court order, or 3) the disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.

Violation of Federal and/or State law and regulations by a treatment facility or provider is a crime. Suspected violations may be reported to appropriate authorities. Federal and/or State law and regulations do not protect any information about a crime committed by a patient, against any person who works for the program, or about any threat to commit such a crime. Federal law and regulations do not protect any information about suspected child (or vulnerable adult) abuse or neglect, or adult abuse from being reported under Federal and/or State law to appropriate State or Local authorities. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is the therapist’s duty to warn any potential victim, when a significant threat of harm has been made. In the event of a patient’s death, the spouse or parents of a deceased patient have a right to access their child’s or spouse’s records. Professional misconduct by a health care professional must be reported by other health care professionals, in which related patient records may be released to substantiate disciplinary concerns. Parents or legal guardians of non-emancipated minor patients have the right to access the patient’s records. When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about patient, not clinical information. My signature below indicates that I have been given a copy of my rights regarding confidentiality. I permit a copy of this authorization to be used in place of the original. Patient data of clinical outcomes may be used for program evaluation purposes, but individual results will not be disclosed to outside sources.

Complaints: If you have any complaints or questions regarding these procedures, please contact ACPC. We will get back to you in a timely manner. You may also submit a complaint to the Joint Commission or U.S. Dept. of Health and Human Services and/or the Texas Department of Health and Human Services. These numbers can be found under the FAQ tab of our website at If you file a complaint ACPC will not retaliate in any way.


As a patient, you have the right to:

  • Receive quality health care by properly trained and licensed mental health professionals.
  • Be treated with respect and dignity.
  • Have your privacy respected.
  • Expect that all communications and records pertaining to your health care are treated as confidential.
  • Receive a copy of and ask questions concerning our Privacy Policy.
  • Receive information concerning your diagnosis, treatment, prognosis, and significant risks in terms you can understand prior to consenting to a procedure.
  • Refuse treatment after adequate explanation by your healthcare provider. However, you must be informed of the medical consequences of this action.
  • Change your healthcare provider, if desired.
  • Inquire about fees for treatment prior to delivery of services.
  • Address concerns and complaints through patient exit survey or our complaint resolution process.

As a patient, you have the responsibility to:

  • Give at least 24 hours notice to cancel any appointment.
  • Arrive on time for your appointment.
  • Provide accurate information concerning your past health history, medications, allergies (including latex), current address, phone number and emergency contacts.
  • Respect the rights of other patients and staff.
  • Follow all Texas State rules and regulations pertaining to safety, smoking and general conduct.
  • Ask questions regarding your diagnosis or treatment.
  • Follow the treatment plan or medical advice.
  • Call your ACPC healthcare provider if your symptoms are not improving or if your symptoms worsen.
  • Keep follow-up appointments to ensure good health care.
  • Plan ahead and be aware of ACPC’s operating schedule because the facility closes during certain holidays or times of the year.
  • Pay for services when rendered.
  • Inform the ACPC of any concerns or complaints.
  • Refrain from using your cell phone during patient care.

Patient’s Rights: I certify that I have received the Privacy Policy and Patient Rights and Responsibilities Policy which includes my rights as a patient and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information from ACPC.

Non-Voluntary Discharge from Treatment: A patient may be terminated from treatment involuntarily, if: A) the patient exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the office, and/or B) the patient refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. The patient will be notified of the involuntary discharge by letter. The patient may appeal this decision or request to re-apply for services at a later date.

I understand the limits of confidentiality, privacy policies, my rights, and their meanings and ramifications.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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