Mental Health Assessment Information Forms and Payment Link

1. Purpose of the Assessment

The purpose of this assessment is to gather information about my mental health, emotional functioning, and behavioral history. 

This assessment is intended to determine whether a clinical mental health diagnosis is present or to rule one out and to provide recommendations if appropriate. A written report summarizing the findings and recommendations will be prepared.

This assessment is for evaluation purposes only. It is not therapy or counseling and does not establish a therapeutic relationship.

2. What the Assessment Includes
I understand that the assessment may include:

A diagnostic clinical interview (biopsychosocial)
Review of personal, family, mental health, and relevant history
Discussion of substance use history (if applicable)
Standardized screening tools or questionnaires
Review of available records 

3. Licensed Professional
I understand that this assessment will be conducted by a licensed professional affiliated with Step Three, Inc., who is trained and qualified to provide mental health assessments within their scope of practice.

4. Voluntary Participation
Participation in this assessment is voluntary.

If this assessment is court-ordered or required by probation, DHS, CPS, or another authority, failure to complete it may result in legal consequences determined by that authority, not by Step Three, Inc.

5. No Guarantee of Outcomes
The findings, results, and recommendations of this assessment do not guarantee any specific outcome.

6. Confidentiality
Information obtained during this assessment will be kept confidential as required by state and federal law.

I understand that confidentiality has limits. Step Three, Inc. is legally required to disclose information without my consent in the following situations:

If there is suspected abuse or neglect of a child, elderly person, or vulnerable adult
If I make a credible threat of serious harm to myself or another person
If disclosure is legally required

7. Acknowledgment
I have read and understand this informed consent. I have had the opportunity to ask questions, and my questions have been answered.

I understand the purpose and limits of this assessment and agree to participate in a mental health assessment with Step Three, Inc.

Each consumer shall be afforded all constitutional and statutory rights of all citizens of the State of Oklahoma and the United States, unless abridged through due process of law by a court of competent jurisdiction. Each consumer has the right to be treated with respect and dignity. Furthermore: Each consumer shall retain all rights, benefits, and privileges guaranteed by law except those lost through due process of law. Each consumer has the right to receive services suited to his or her condition in a safe, sanitary and humane treatment environment regardless of race, religion, gender, ethnicity, age, degree of disability, handicapping condition or sexual orientation. No consumer shall be neglected or sexually, physically, verbally, or otherwise abused. 

 Step Three, Inc shall ensure each consumer has the rights which are listed below: 

Each consumer has the right to be treated with respect and dignity. This shall be construed to protect and promote human dignity and respect for individual dignity. 

Each consumer has the right to receive services without regard to his or her race, religion, sex, color,ethnic origin, age, national origin, genetic information, religion,degree of disability, handicapping condition, or legal status.

Each consumer has the right to refuse to participate in any research project or medical experiment without informed consent of the client, as defined by law. A refusal to  participate shall not affect the services available to the client. 

Each consumer has the right to assert grievances with respect to any alleged infringement of these stated rights of clients, or any other subsequently statutorily granted rights. 

No consumer shall ever be retaliated against, or subject to, any adverse conditions or services solely or partially because of having asserted the rights as stated in this section.

Each consumer has the right to know why services are refused and can expect an explanation concerning the reason he or she was refused certain services. (b) Each client shall be given a copy of these rights and the provision of such shall be documented in the consumer record.

My signature indicates I understand that I am the consumer and that I have read and understand my rights and have been offered a copy of this document. 

Step Three, Inc. complies with all applicable state and federal laws governing the privacy and confidentiality of mental health information.

Information obtained during a mental health assessment, whether written or verbal, is confidential and will not be released to another individual or agency without your written authorization, except as permitted or required by law.

Confidential information may be disclosed without your written consent in the following circumstances:

If there is suspected abuse or neglect of a child, elderly person, or vulnerable adult
If you make a credible threat of serious harm to yourself or another person
If disclosure is required by a valid court order, subpoena, or other lawful legal process
As otherwise required by state or federal law

Access to mental health assessment information is limited to authorized personnel and only to the minimum necessary information required for legitimate professional or legal purposes.

Acknowledgment

My signature below acknowledges that I have been informed of my rights regarding confidentiality. I understand the limits of confidentiality and the circumstances under which information may be disclosed without my consent.

An individual receiving a mental health assessment at Step Three, Inc. has the right to assert a grievance regarding any alleged infringement of rights. 

No individual shall be subjected to retaliation, discrimination, reprisal, or adverse consequences for asserting his or her rights or filing a grievance.

An individual has the right to:

Voice concerns regarding the assessment process or professional conduct
Request an internal review of the assessment findings
Obtain the opinion of an outside licensed medical or mental health professional at his or her own expense

Grievance Procedure
If an individual believes a grievance exists, the grievance may be submitted orally or in writing to Step Three, Inc.

Grievances may be directed to:

Misti Luke, LCSW- Director
Step Three, Inc.
815 W. Choctaw Street
Phone: 580-584-6622 

 

A written summary of the grievance will be prepared. Every reasonable effort will be made to review and resolve the grievance in a timely manner.

A written response outlining the findings and any actions taken will be provided within one (1) week of receipt of the written grievance.

If the individual is not satisfied with the resolution, the grievance may be forwarded to the Step Three, Inc. Board of Directors for further review. Contact information for the Board of Directors is posted in the Broken Bow office.

External Complaint Rights
In addition to the internal grievance process, an individual has the right to file a complaint, with or without notifying Step Three, Inc., with the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS).

ODMHSAS Office of Consumer Advocacy
2401 NW 23rd Street
Oklahoma City, OK 73107
Toll Free: (866) 699-6605
Local: (405) 248-9037
Email: AdvocacyDivision@odmhsas.org
Reachout Hotline: (800) 522-9054

No adverse consequences or reprisals will occur as a result of filing a grievance or complaint.

Acknowledgment
My signature below indicates that I have been informed of my right to file a grievance and have been offered a copy of this document.

If I choose to participate in a mental health assessment by secure video (telehealth), I understand and agree to the following:

Technology Requirements
I must have a stable internet connection and an updated device capable of secure video communication.
I am responsible for ensuring my device is functioning properly prior to the session.
I understand that technical difficulties may interrupt or delay the assessment.

Privacy Requirements
I must participate from a private and confidential location.
I cannot not participate while driving or while in a moving vehicle.
I agree not to record the assessment without prior written permission.

Emergency Contacts
In the event of an emergency during an online assessment, I authorize Step Three, Inc. to contact emergency services and my emergency contact. 

Physical Location Requirements
I understand that I am not required to be a resident of Oklahoma; however, I must be physically located within the State of Oklahoma at the time the assessment is conducted.

I understand that if I am physically located outside the State of Oklahoma at the time of the assessment, the assessment will not proceed.

 Acknowledgment
I have read and understand the requirements and limitations of participating in a telehealth / online mental health assessment. I agree to comply with these requirements.

This authorization will remain valid for one (1) year from the date of my signature below, unless I revoke it in writing sooner.

I understand that:

This authorization is voluntary.
I may revoke this authorization at any time by submitting a written revocation to Step Three, Inc., except to the extent that action has already been taken in reliance on it.
Information released under this authorization may no longer be protected by federal privacy laws if disclosed to a person or agency not subject to those laws.