Permission To Treat Form
Purpose of Volunteer Behavioral Health’s Permission to Treat
This comprehensive consent form authorizes Volunteer Behavioral Health (VBH) to provide mental health services while establishing the legal, financial, and operational framework for treatment.
Key Components:
Treatment Authorization
• Grants staff permission to provide clinically necessary mental health services
• Authorizes diagnostic and treatment procedures essential for patient care
Patient Rights & Legal Protections
• Acknowledges receipt of Client Rights & Responsibilities documentation
• Confirms compliance with non-discrimination policies (Title VI, Section 504)
• Addresses professional boundaries and ethical standards
• Covers supervision of unlicensed staff and HIPAA compliance
Privacy & Communication
• Establishes electronic health record protocols and PHI handling
• Sets communication preferences (phone, email, text messaging)
• Includes photography consent for identification purposes
• Provides confidentiality protections with emergency exceptions
Financial Responsibilities
• Outlines fee structure and payment expectations
• Authorizes insurance billing and information release for claims processing
• Establishes patient responsibility for uncovered services and collection costs
• Offers self-pay agreement options
Care Coordination
• Promotes integrated care model (Tennessee Health Link) for optimal outcomes
• Addresses primary care physician communication options
• Includes telehealth service consent
• Covers advance directives and mental health treatment declarations
Safety & Orientation
• Provides facility safety information (exits, fire equipment, first aid)
• Establishes emergency procedures and crisis contacts
The form requires signatures from patients (and guardians when applicable) to confirm understanding and agreement to all terms before treatment begins. To preview the PDF version of the document, scroll down to the webform at the bottom, and to complete it online click “Start Signing”.