Consent for Treatment
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   ROI-Orchard Medical


Your Rights for Information Privacy

(This is a required notice that you must read before we can provide treatment services. Please read carefully and sign at the bottom)

Your rights are described in this document. Ask your Therapist or Member Services if you have any questions.

1.    Privacy of Information: All information we gather about you during admission and treatment will remain private and only be shared with your written consent or as legally required by federal, state or local laws.

2.    Involuntary Termination and Re-admission: You may be terminated from our services for (1) non-compliance with program rules, (2) non-payment, or (3) Therapist determines that our services are not benefitting your conditions. Readmission will only be considered upon a re-assessment that determines the deficiencies that caused involuntary termination have been corrected and that you are “appropriate” for our services.

3.    Freedom from Potential Harm or Acts of Violence: All Members must abide by strict program rules concerning behavior while attending treatment. If you are uncomfortable with any Member’s behavior during sessions, please discuss with your therapist in private. If you are uncomfortable with the behavior of any member of your treatment team, please discuss with Recovery Help management as soon as possible.

4.    Member Responsibilities: You are responsible to (1) attend schedule treatment, (2) complete self-learning modules, (3) participate willingly in group sessions, (4) comply with all program rules and (5) conduct yourself in a responsible manner at all times.

5.    Service Fees and Costs:  You will be presented with a financial agreement during the admission process outlining the scope of recommended services and associated costs.

6.    Grievance and Complaint procedures:  If you have any concerns or complaints, please submit them in writing to management.

7.    Freedom from Discrimination:  Recovery Help does not discriminate because of race, color, national origin, religion, sex, disability, age, citizenship status, genetic information, veteran or familiar status.

8.    Dignity: You have the right to be treated with dignity at all times.

9.    Communication, visitation, and mail: Since all treatment is outpatient, Recovery Help has no jurisdiction over your communication, visitation or mail with others. However, your Therapist may recommend that you avoid communication with certain individuals who will be detrimental to your recovery.

10. Smoking: Recovery Help has a defined no-smoking policy both in a facility and on video conference.

11. Maximum Sanctions: You may be terminated from our services for (1) non-compliance with program rules, (2) non-payment or (3) Therapist determines that our treatment is not benefitting your conditions.

12. Right for Review: You have the right to consult with another Medical professional or state regulatory agency concerning your diagnosis or treatment plan.

Electronic Signature

I understand that when I interact online with Recovery Help systems and websites that my typed name becomes my electronic signature instead of written signatures. I also understand that faxed or scanned copies of documents with my signature are to be considered original signatures.


I have read and understood these Member Rights

Signature (Type Your Name)..