Informed Consent

for Assessment & Treatment

I understand that I am eligible to receive a range of services from my provider. The type and extent of services that I
receive will be determined following an initial assessment and thorough discussion with me. The goal of the
assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the
course of several weeks.

I understand that I have the right to ask questions throughout the course of treatment and may request an outside
consultation. (I also understand that my provider may provide me with additional information about specific treatment
issues and treatment methods on an as-needed basis during the course of treatment and that I have the right to
consent to or refuse such treatment). I understand that I can expect regular review of treatment to determine whether
treatment goals are being met. I agree to be actively involved in the treatment and in the review process. No promises
have been made as to the results of this treatment or of any procedures utilized within it. I further understand that I
may stop treatment at any time, but agree to discuss this decision first with my provider.

I am aware that I must authorize my provider, in writing, to release information about my treatment but that
confidentiality can be broken under certain circumstances of danger to myself or others. I understand that once
information is released to insurance companies or any other third party, that my provider cannot guarantee that it will
remain confidential. When consent is provided for services, all information is kept confidential, except in the following
circumstances:

• When there is risk of imminent danger to myself or to another person, my provider is ethically bound to take
necessary steps to prevent such danger.

• When there is suspicion that a child or elder is being sexually or physically abused, or is at risk of such abuse, my
provider is legally required to take steps to protect the child, and to inform the proper authorities.

• When a valid court order is issued for medical records, my provider is bound by law to comply with such
requests.

While this summary is designed to provide an overview of confidentiality and its limits, it is important that you read the
Notice of Privacy Practices which was provided to you for more detailed explanations, and discuss with your provider any
questions or concerns you may have.

By my signature below, I voluntarily request and consent to behavioral health assessment, care, treatment, or services
and authorize my provider to provide such care, treatment or services as are considered necessary and advisable. I
understand the practice of behavioral health treatment is not an exact science and acknowledge that no one has made
guarantees or promises as to the results that I may receive. By signing this Informed Consent to Treatment Form, I
acknowledge that I have both read and understood the terms and information contained herein. Ample opportunity has
been offered to me to ask questions and seek clarification of anything unclear to me.

for Telehealth Services

Definition of Telehealth
Telehealth involves the use of electronic communications to enable professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

I understand that I have the rights with respect to telehealth:

1. I understand privacy and the confidentiality laws apply to telehealth, and that no inf01mation obtained through the use of telehealth services will be disclosed to researchers or other entities without my written consent.

2. My health care provider has explained how the videoconferencing technology will be used to conduct a telehealth session, that unlike a direct patient/provider in person, I will not be in the same room as my health care provider.

3. I understand the potential risks to technology including interruptions, unauthorized access and technical difficulties. I understand my health care provider or I can discontinue the videoconference consult/visit if it is believed videoconferencing technologies are not adequate for the situation.

4. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

5. I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

6. I understand that no results for anticipated benefits can be guaranteed or assured by my provider.

7. I understand my healthcare information may be shared with other individuals for purposes of scheduling and billing. Individuals other than my healthcare provider may be present during the session in order to operate videoconferencing equipment. I further understand that I will be informed of their presence, and that such individuals will maintain confidentiality on information obtained during the session. Furthermore, I have the right to request the following:

• ask non-medical personnel to leave the telehealth examination room; and/ or
• terminate the consultation at any time.

8. I agree certain situations - such as emergencies and crisis -- are inappropriate for audio-/video-/computer based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis-oriented healthcare facility in my immediate area.

Consent to The Use of Telehealth

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents including the risks and benefits of the procedure(s).
• That I have been given ample oppo11unity to ask questions and that any questions have been answered to my satisfaction.

This notice applies to the following entities:

Freedom Healthcare, LLC dba Community Wellness Center, 3310 Eastern Avenue, Baltimore, MD 21224
Freedom Health Systems, Inc., 3310 Eastern Avenue, Baltimore, MD 21224
Community Wellness Outpatient Mental Health Center, LLC, 3310 Eastern Avenue, Baltimore, MD 21224
Community Wellness Psychiatric Rehabilitation Program, LLC, 3310 Eastern Avenue, Baltimore, MD 21224
HolBrock Estates Supportive Housing Programs, LLC, 3310 Eastern Avenue, Baltimore, MD 21224
Lighthouse Behavioral Health Center, LLC, 1119 E Monument Street, Baltimore, MD 21202

Effective date of this Privacy Policy notice

This notice is effective January 1, 2023.

Privacy Official contact information

The Privacy Official is designated as Jevon Patrick, LMSW. His email address is clinicaldirector@cwcmd.org. His phone number is 443-708-5056 EXT 1001.