form16

FR0318FI Clinical Trainee-Clinical Intern Informed Consent

INFORMED CONSENT FOR CLINICAL TRAINEE/CLINICAL INTERN TO PROVIDE MENTAL HEALTH SERVICES TO CLIENTS
Client's Name
By 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
MM slash DD slash YYYY
Signature of Clinical Trainee/Clinical Intern
MM slash DD slash YYYY
Signature of Southern Minnesota Behavioral Health Supervisor
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.
Call Now