Client Consent Form

Client Consent Form

Agency Information
Agency Name:
Agency Address:
City, State, ZIP:
Phone Number:
Email Address:
Client Information
Client Full Name:
Date of Birth:
Address:
City, State, ZIP:
Phone Number:
Email Address (Optional):
1. Consent for Services
I,
(Client Name), voluntarily consent to receive services from
(Agency Name) as outlined in my Individual Service Plan (ISP), Care Plan, Treatment Plan, Program Plan, or other written service agreement.

I understand that services may include (but are not limited to):

  • Personal Care or Support Services
  • Medical or Health-Related Services (if applicable)
  • Behavioral Health or Mental Health Services
  • Companion or Supervision Services
  • Residential, Day Program, or Community-Based Services
  • Assistance with Activities of Daily Living (ADLs)
  • Case Management or Care Coordination
  • Educational, Therapeutic, or Support Programs
Client Signature:
Date:
2. Authorization for Use and Disclosure of Information (HIPAA / Privacy)
I authorize
(Agency Name) to collect, use, and disclose my personal, medical, and service-related information as necessary to:
  • Provide and coordinate services
  • Communicate with healthcare providers or professionals
  • Process billing, insurance, Medicaid, or funding sources
  • Maintain service records and documentation
  • Comply with legal and regulatory requirements
I understand: My information will be protected under HIPAA and applicable law. I may revoke this authorization at any time in writing (except where already used).
Client Signature:
Date:
3. Emergency Contact Authorization
Emergency Contact Name:
Relationship to Client:
Phone Number:
Alternate Contact Name (Optional):
Phone Number:
4. Photography and Video Consent (Optional)

Purpose may include documentation, training, compliance, or promotional use.

  • I Consent
  • I Do NOT Consent
Client Signature:
Date:
5. Acknowledgment of Client Rights and Responsibilities

I acknowledge that I have received and understand my rights, including:

  • Respectful, dignified, non-discriminatory care
  • Participation in care planning and decisions
  • Privacy and confidentiality
  • Access to records (as permitted by law)
  • Right to file complaints without retaliation
  • Right to refuse or discontinue services
Client Signature:
Date:
6. Communication Preferences (Optional)
  • Text message reminders / updates
  • Voicemail messages allowed
  • Communication with family/authorized representatives
  • Participation in surveys / quality improvement
Preferred Method of Contact:
7. Financial & Service Responsibility Acknowledgment

I understand that I am responsible for:

  • Payment of services not covered by insurance
  • Providing accurate insurance/financial information
  • Notifying the agency of changes in coverage
I understand that non-payment may affect continuation of services per agency policy.
Client Signature:
Date:
8. Final Acknowledgment

By signing below, I confirm:

  • I have read and understand this form
  • I voluntarily consent to receive services
  • I may withdraw or modify consent in writing at any time
Client Signature:
Date:
Authorized Representative (If Applicable)
Representative Name:
Relationship to Client:
Signature:
Date: