61 Clinical Trainee-Clinical Intern Informed Consent

INFORMED CONSENT FOR CLINICAL TRAINEE/CLINICAL INTERN TO PROVIDE MENTAL HEALTH SERVICES TO CLIENTS
Client's Name(Required)
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(Required)
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.

the office closed September 1, 2023.
If you are looking for your medical record, please contact Counseling Services of Southern Minnesota, St. Peter.