WP E-Signature by Approve Me - Sign Documents Using WordPress -

Mental Health Bill of Rights - eSignature

Minnesota CarePartner
393 N Dunlap St. #300 St. Paul, MN 55104
P: 612-289-5656 F: 651-925-0278

Minnesota CarePartner Mental Health Bill of Rights

Client Name:

Client Date of Birth:

Person Signing this form is:

Name of Person Signing this Form:

As a Minnesota CarePartner client, you have a right to:

Receive respectful treatment
Refuse treatment or a particular intervention strategy
Ask questions at any time
Know-how available the counselor is to see you or what the waiting period is
Have full information about fees, method of payment, and insurance reimbursement
Have full information regarding the counselor's qualifications to practice, including licensure or registration, training, and experience
Have full information regarding the counselor's areas of specialization and limitations
Have full information about the counselor's therapeutic orientation and any technique which is routinely used
Have full information regarding your diagnosis if your counselor uses one
Choose a counselor with whom you feel you can work
Experience a safe setting, free from physical, sexual, or emotional abuse
Agree to a written contract of counseling goals and treatment plan
Request that the therapist evaluate the progress of counseling
The right to be allowed access to records and written information from records in accordance with the State of Minnesota Statutes, section 144.335
Require the therapist to send a report regarding your therapy with your written authorization
Confidentiality regarding records and transactions, unless you have signed and authorized, in writing, a release of records, or as otherwise required by law
Information regarding other services that may be available in the community and the freedom to change the provider of service
Coordinated transfer when there has been a change in provider of services
To assert the client's rights without retaliation
Complaints can be made to:
- Minnesota Board of Social Work 612-617-2100
- Office of Ombudsman (BHP referrals), 612-296-0382 or 800-657-5391
- United States Department of Health and Human Services, 877-696-6775

As a recipient of services from a Licensed Marriage and Family Therapist, you have a right:

to expect that a therapist has met the minimal qualifications of education, training, and experience required by state law;
to examine public records maintained by the Board of Marriage and Family Therapy that contain the credentials of a therapist;
to report complaints to the Board of Marriage and Family Therapy;
to be informed of the cost of professional services before receiving the services;
to privacy as defined and limited by rule and law;
to be free from being the object of unlawful discrimination while receiving services;
to have access to their records as provided in Minnesota Statutes, sections 144.291 to144.298, except as otherwise provided by law or prior written agreement;
and to be free from exploitation for the benefit or advantage of a therapist.

As a recipient of services from a licensee of the Minnesota Board of Behavioral Health and Therapy, you have a right to:

expect that the provider meets the minimum qualifications of training and experience required by state law;
examine public records maintained by the Board of Behavioral Health and Therapy that contain the credentials of the provider;
report complaints to the Board of Behavioral Health and Therapy;
be informed of the cost of professional services before receiving the services;
privacy as defined and limited by law and rule;
be free from being the object of unlawful discrimination while receiving counseling services;
have access to their records as provided in sections 144.92 and 148F.135, subdivision 1, except as otherwise provided by law;
be free from exploitation for the benefit or advantage of the provider;
terminate services at any time, except as otherwise provided by law or court order;
know the intended recipients of assessment results;
withdraw consent to release assessment results, unless the right is prohibited by law or court order or was waived by prior written agreement;
a nontechnical description of assessment procedures; and
a non-technical explanation and interpretation of assessment results, unless this right is prohibited by law or court order or was waived by prior written agreement.

Attestation to Contents of and Orientation to Bill of Rights

I have read and understand the Mental Health Bill of Rights

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

August 9, 2021 8:05 am CDT

Mental Health Bill of Rights - eSignature Uploaded by Roots Recovery - rootsforms@mncarepartner.com IP 101.50.73.57