form16 FR0318FI Clinical Trainee-Clinical Intern Informed Consent INFORMED CONSENT FOR CLINICAL TRAINEE/CLINICAL INTERN TO PROVIDE MENTAL HEALTH SERVICES TO CLIENTSClient's Name First Last Client’s NumberBy signing this consent, I permit the below-named Clinical Trainee/Clinical Intern to provide mental health services to either myself or to an individual for whom I have legal guardianship. I understand the Clinical Trainee/Clinical Intern: Will Not have their supervisor present during therapy sessions; Receives supervision by a licensed mental health professional employed by Southern Minnesota Behavioral Health and, if a Clinical Intern, academic internship supervisor from their college or university; Will be reviewing my case with their Southern Minnesota Behavioral Health supervisor for purposes of evaluating the Clinical Trainee’s/Clinical Intern’s clinical skills; Will be held to the same professional and legal standards, which includes protecting my confidential information as Licensed Mental Health Professionals.Signature of Client/Parent/Legal Guardian First Last Date MM slash DD slash YYYY Signature of Clinical Trainee/Clinical Intern First Last Date MM slash DD slash YYYY Signature of Southern Minnesota Behavioral Health Supervisor First Last Date MM slash DD slash YYYY A copy of this document will remain a part of your records consistent with the Minnesota Data Privacy Act and HIPAA. This authorization expires one year from the client signature date.CAPTCHA
