form09 FR0153 United Behavioral Health (UBH) Therapist Consent Form United Behavioral Health (UBH) Therapist Consent Form Each insurance company has a set of guidelines and standards that treatment providers must adhere to in order to provide services to persons having that insurance. Southern Minnesota Behavioral Health has several Licensed Mental Health Professionals. Some of these professionals are “credentialed” by UBH and some are not. Southern Minnesota Behavioral Health assigns clients to therapists that we assess are a good clinical match and attempt to match expertise with specific client need. UBH requires that you are informed whether or not the therapist you are seeing is a UBH credentialed therapist. If you wish to see a therapist at Southern Minnesota Behavioral Health that is not a UBH credentialed therapist, you must consent to do so. You have a right to see only UBH credentialed therapists, and we would ask that you indicate this also.Please check one: I consent to see only a UBH credentialed therapist. I consent to see a non-UBH credentialed therapist, under the supervision of a UBH credentialed therapist. Client Signature First Last Date MM slash DD slash YYYY Parent/Guardian Signature First Last Date MM slash DD slash YYYY Staff Witness First Last Date MM slash DD slash YYYY CAPTCHA
