Consent for Services and Rights and Responsibilities Consent for Services and Rights and Responsibilities 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. These services should be conducted: On-site Off-site Both On-site and Off-site 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. First Name Last Name Email Signature Signature of Person/legal guardian for Persons Clear Undo Redo Relationship to Person Self Legal Guardian Surrogate Decision Maker Court Appointed Rep. Other... Rights and Responsibilities 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): Rights Treatment Confidentiality Advance Directive Suggestions, recommendations, and complaints I may revoke my consent for treatment at any time Privacy Working together with Primary Care Physician Responsibilities Payment for Services (if required) Changes in personal information Personal property Medication Disclaimer Cancellation for appointments Waiting room policies Sign in and out Signature Signature of Person/legal guardian for Persons under 16 Clear Undo Redo Submit
