Step 1 of 4

  • CONSENT TO TREAT AND PERMISSION TO RELEASE INFORMATION

  • I understand that the Children’s Advocacy Center of the Bluegrass (CACBG) is providing a mental health assessment and treatment service(s) to my child or the child in my custody.

    I understand that there are no certain outcomes from these services and that individual experiences with treatment may vary. It is important to work with the therapist to decide when therapy goals have been reached and when services shall be terminated, but overall I understand that I do have the right to stop therapy services at any time.

    In giving consent to the CACBG to provide these services to my child or the child in my custody, I am aware that the CACBG has a duty to protect my confidentiality except where the law requires disclosure of certain information.

    There are several situations in which the Center cannot assure confidentiality including:
    1. The Center has a duty to report the abuse or neglect of a dependent adult and/or domestic violence offenses to the Cabinet for Health and Family Services;
    2. The Center has a duty to report any instance of child neglect, exploitation or abuse to the Cabinet for Health and Family Services and/or law enforcement;
    3. The Center has a duty to report any threats against persons to the intended victim and to the police;
    4. The Center has a duty to release information to agencies or persons with a need to know when a client is in need of hospitalization; and
    5. When a client introduces personal mental health issues in court proceedings, then the client waives confidentiality.
    Understanding all of the above possible waivers of confidentiality regarding information about my mental health condition and treatment, I give consent to CACBG to provide assessment and treatment services to my child or the child in my custody.

    In giving permission for services, I also give consent to release information from the CACBG record of my child or the child in my custody to our service region’s Multidisciplinary Team stated below. The release refers to all relevant in- formation pertaining to the abuse of the child named below for the purpose of assisting in coordinating services. My consent includes the permission for CACBG staff to utilize electronic communications such as email when communicating with community partners listed below. I may revoke this consent at any time I chose by informing the Center.

    Multidisciplinary Team Members: Commonwealth Attorney’s Office, Kentucky State Police, Government Police Department, Cabinet for Health and Family Services Department for Community Based Services, bluegrass.org, Center for Women, Children and Families, Court Appointed Special Advocates, and Guardian Ad Litem.

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Federal rules prohibit any party from making further disclosure of this information “unless further disclosure is expressly permitted by the written consent of the person to whom it pertains” or is otherwise permitted by 42 CFR Part 2.