I give my consent to be seen for the Psychiatric Rehabilitation Services and/or assessments by Crossroads, Inc. providers. I also consent to Crossroads, Inc. providing information to the Baltimore County’s Core Service Agency for the purposes of providing statistical reports to the State of Maryland.

I also understand

• The nature and purpose of Crossroads, Inc., possible alternative methods of treatment, and possible risks involved.
• That violation of program rules may result in discharge from the program, and I hereby release the program from any liability arising from any damage, injury, or harm resulting from any such violation of these rules on my part.
• That I may revoke my consent at any time.

I have received a copy of the “Rights and Responsibilities” document outlining Crossroads, Inc.; services, policies, and person’s rights and responsibilities for its and psychiatric rehabilitation program.  I understand what I read, and agree to follow these procedures, which include (please initial on the line):