SHARE Wellness Center

Services are individualized and may change based on clinical need and provider recommendation.

I voluntarily consent to receive outpatient mental health services, including therapy and medication management, at Share Wellness Center. I understand: - The nature of services provided - My rights and responsibilities - That participation is voluntary - That treatment requires active participation

I voluntarily consent to evaluation, assessment, treatment, psychiatric rehabilitation, counseling/therapy, psychiatric services, substance use services, care coordination, and/or other behavioral health services provided by Share Wellness Center, limited to the services for which I am admitted and that are clinically appropriate. I understand that the nature, purpose, expected benefits, material risks, alternatives, and possible consequences of refusing recommended services will be explained to me as appropriate. I may ask questions and may withdraw consent or refuse a service, subject to applicable law, emergency circumstances, payer requirements, and the clinical consequences explained to me. I understand that participation does not guarantee a specific outcome and that my treatment/recovery plan will be individualized and reviewed with me.

I understand that telehealth uses electronic communication for behavioral health services. Potential benefits include improved access and convenience. Potential limitations include technology failure, privacy/security risks, limits of remote assessment, and the possibility that in-person or emergency care may be recommended. I agree to provide my physical location and an emergency contact when requested for telehealth safety. I understand that I may ask to stop a telehealth session and discuss alternatives when clinically appropriate.

I acknowledge that I was offered/provided Share Wellness Center's Notice of Privacy Practices and information about confidentiality. I understand that my health information may be used or disclosed for treatment, payment, and health care operations as permitted by law, and that other uses/disclosures may require my written authorization unless otherwise permitted or required by law. I understand that certain behavioral health and substance use information may receive additional protections under federal or Maryland law. I may request restrictions or confidential communications as permitted by law and policy.

I understand that ordinary email and text messaging can carry privacy risks. I choose the following communication preferences and understand that I may update them in writing.

My Rights Include: - Be treated with dignity, respect, consideration, and without unlawful discrimination. - Receive appropriate services in a safe setting and participate in decisions about my care. - Receive information in a way I can understand, including reasonable language and accessibility assistance. - Receive services according to my individualized plan of care or rehabilitation plan, as applicable. - Give informed consent and refuse treatment after possible consequences are explained, subject to applicable law. - Privacy and confidentiality of my information as provided by law. - Be free from abuse, neglect, exploitation, mistreatment, retaliation, and inappropriate coercion. - Make suggestions, complaints, or grievances without retaliation and receive information about the grievance process. - Know the names/roles of persons providing my care and ask questions about services. - Participate in discharge/transition planning and receive information needed for continuing care. - Have applicable mental health advance directive preferences respected in accordance with Maryland law. - Contact legal counsel, advocacy resources, and appropriate governmental oversight agencies as permitted by law. My Responsibilities Include: - Provide accurate and complete information to the best of my ability. - Participate in treatment/recovery planning and communicate concerns or changes in my condition. - Treat staff and others respectfully and follow safety rules. - Attend scheduled services or provide reasonable notice when unable to attend. - Ask questions when I do not understand information or instructions. - Provide current insurance/contact information and meet agreed financial responsibilities, when applicable.

I understand that I may raise a concern or grievance about services, discharge, changes in services/status, staff conduct, privacy, or other program decisions without fear of retaliation. I was informed how to submit a grievance and how to request assistance with the process. Share Wellness Center grievance contact/title: Phone/Email: I understand that I may also contact applicable external advocacy, local behavioral health authority, Maryland Behavioral Health Administration/Department of Health, or other oversight resources when appropriate. Current contact information should be maintained on the organization's grievance notice/posting.

I understand that Share Wellness Center is not a substitute for emergency services. For an immediate life-threatening emergency, call 911 or go to the nearest emergency department. For behavioral health crisis support, call or text 988. I will use other local/mobile crisis resources provided by the program when appropriate.

An advance directive allows a person to state health care preferences and/or name someone to make health care decisions if the person later cannot make or communicate those decisions. Maryland law also permits an advance directive for mental health services. Share Wellness Center will document whether an advance directive exists and, when applicable, place a copy in the record or document how it can be obtained. I understand that this acknowledgment does not require me to create an advance directive and that services will not be denied solely because I do not have one.

I authorize Share Wellness Center to submit claims and necessary supporting information to my insurer/payer as permitted by law. I understand that coverage and authorization do not guarantee payment and that any client financial responsibility will be explained according to applicable law, payer contract, and Company policy.

I understand that regular participation and timely communication support continuity of care. Share Wellness Center will explain program-specific attendance expectations, missed-appointment procedures, discharge/transition criteria, and how to request re-engagement or appeal/grieve a program decision when applicable.

By signing below, I acknowledge that I had the opportunity to review this enrollment packet, ask questions, and receive assistance in a language/format I understand. My signature confirms receipt/acknowledgment of the sections indicated above; it does not waive any legal rights or authorize optional disclosures or media use unless I separately selected and signed those sections.