INFORMED CONSENT FOR PARTICIPATION IN MENTAL HEALTH

SERVICES

As a client of AMITA Health Center for Mental Health, I have received a copy of my
rights and have had the opportunity to ask questions about the services I may receive. I
am agreeing voluntarily to receive and participate in mental health services at Alexian
Brothers Center for Mental Health. I am also agreeing to follow the agency expectations
for participation in mental health services. I understand that I may choose to withdraw
from services at any time in the future.

I expressly consent for AMITA Health Center for Mental Health, its providers and agents
to place calls to my cellular and/or residential phone using artificial or pre-recorded
voice or auto-dialer technologies for any follow-up purposes, including billing and
collections.

__________________________________ ________________
Client signature (age 12 or older) Date

__________________________________ ________________
Guardian signature (required if client is under 18) Date

__________________________________ ________________
Staff signature Date

Note: Consent must be obtained prior to the initiation of mental health services.

Date Guardian notified of need for signature: ________________________________

CENTER FOR MENTAL HEALTH Client Name ______________________________________

3436 N. Kennicott Avenue Client I.D.# _____________________________________
Arlington Hts., IL 60004
M:\Forms-ABCMH\Opening Paperwork\InformedConsent Rev 09/19