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Family Counseling Program Informed Consent & Clients’ Rights

Informed Consent and Clients’ Rights Forms

Be sure to read and fill out this form, as well as the Client Intake form, to start the process with one of our licensed counselors.

  • You may either complete the on-line consent form below, or
  • you may download the form, type your answers directly into the form, and submit it to our e-mail.

Welcome to the Counseling Program of The Center for Youth and Family Solutions. We would like you to understand several important aspects of how we work.

Therapeutic Approach: During the therapy process, you and your therapist are active participants. The therapist assists you in identifying problem areas, treatment goals, and in evaluating alternative solutions. Your therapist will attempt to assist you in resolving your presenting problem. Our primary therapeutic approach is relationship based on Family Systems Theory and/or Trauma Informed Practice.

Alternative Treatments: Possible alternative treatments to therapy may include, but are not limited to, medication, residential treatment, inpatient and/or partial hospitalization, private behavioral treatment, and psycho-education.

Expected benefits: The goal of therapy will be to resolve the problems you identify with your therapist. We cannot guarantee that you will make progress, but most clients find that they get out of counseling what they put into it.

Expected duration: The duration of services is based on treatment goals, court orders, and your motivation and willingness to make changes which address the identified problems.

Risks: Sometimes it is difficult to discuss certain problems. You may need to struggle with some painful issues in order to achieve your goals.

Confidentiality:. We adhere to the Mental Health and Developmental Disabilities Confidentiality Act and the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and the Health Information Technology for Economic and Clinical Health Act (HITECH). The Center for Youth and Family Solutions will not share information about you with anyone without your written permission. The following are exceptions to this code:

  • your worker may give information about you without your permission, to their supervisor, a consulting therapist, your guardian, or other The Center for Youth and Family Solutions workers who are involved in providing your treatment;
  • if you are in danger of hurting yourself or others, proper authorities will be notified;
  • a specific court order requiring your worker to reveal information about your case during judicial proceedings;
  • If your case is a DCFS child welfare case, periodic progress reports will be given to the court without your expressed consent.
  • By law, we are required to report any suspicion of child abuse to the Department of Children and Family Services and suspected elder or animal abuse to the appropriate local authorities.

Your Rights: Your rights will be protected according to Chapter 2 of the Mental Health and Developmental Disabilities Code [405 ILCS 5].

  • You have the right to remain free from abuse, neglect, and exploitation while in the care of The Center for Youth and Family Solutions. You have the right to report incidents of child abuse, neglect, or exploitation to the State Child Abuse Hotline (1-800-252-2873).
  • You will not be denied services because of age, gender, gender identity, gender expression, race, sexual orientation, religious belief, ethnic origin, marital status, physical disability or mental disability.
  • You will not have services denied, reduced, suspended or terminated for exercising any of your rights.
  • You have the right to be notified of any client rights restrictions, and to have your parent or guardian notified and/or any agency you designate if any of your client rights are restricted. Justification of right restrictions will be documented in your client record. Documentation shall include a plan with measurable objectives for restoring the client’s rights that is signed by the client or the client’s parent or guardian, the QMHP and LPHA. In addition, the client affected by such restrictions, his or her parent or guardian, as appropriate, and any agency designated by the client (i.e. Equip for Equality and/or Guardianship & Advocacy Commission) shall be notified of the restriction and given a copy of the plan to remove the restriction of rights.
  • You have the right to be treated in a way which acknowledges and respects your culture and values.
  • The right to be provided mental health services in the least restrictive setting.
  • The right to have disabilities accommodated as required by the Americans with Disabilities Act, section 504 of the Rehabilitation Act and the Human rights Act (775 ILCS 5).
  • The right to contact HFS or its designee and to be informed by HFS or its designee of the client’s healthcare benefit and the process for reviewing grievances.

Fees: Any associated financial costs will be explained to you by your assigned therapist.

Hours: Office hours are 9:00am – 5:00pm and by appointment.

Professional Standards and Qualifications: The Center for Youth and Family Solutions attempts to provide clients with the highest quality service. Our counseling staff is composed of therapists with educational backgrounds in marriage and family therapy, social work, psychology, and related disciplines. For that reason we adhere to the standards of the American Association of Marriage and Family Therapy, National Association of Social Workers, and National Association of Certified Counselors. These organizations govern the respective professions with established standards for licensing and ethical standards of practice. Your therapist will inform you of their individual qualifications.

Therapist’s Responsibilities: Your therapist is responsible for providing you with high quality professional service. Your therapist is responsible for devoting time and energy to your concerns and to show you respectful and serious attention. Part of your therapist’s responsibility is to seek clarification of your problems, and to help you evaluate alternatives and potential ways of successfully reaching your goals. This may include referral for specialized services beyond the expertise of your therapist.

Your Responsibilities: It is important that you be on time for your appointment and that you please try to call 24 hours in advance if you are unable to keep your appointment. If cancellation is necessary, call your therapist to reschedule your appointment. Phone number is listed below.

The Use of Audio-Visual Recordings: In order to improve the clinical skills of staff, we frequently ask clients to allow us to videotape their therapy sessions. These videotapes are reviewed by your therapist and his/her supervisor to confirm the therapist’s understanding of your concerns and to determine how he/she can be the most helpful to you. Videotapes are erased following supervisory review. They do not become part of your client record and are the sole property of The Center for Youth and Family Solutions. Only your written authorization to audiotape or videotape your therapy sessions will allow us this opportunity. If you permit the taping of your therapy sessions, an Authorization To Record/Observe Therapy Sessions Form will be provided for your signature.

Quality Assurance: It is important to us that you receive effective treatment and that you have the opportunity to give feedback about that treatment. Consequently, you will be asked to complete a variety of surveys and questionnaires both during and after your treatment experience. Your feedback will be used to improve Foster Care Counseling Program services.

Your Satisfaction is Important: Please feel free to raise any concerns about your therapy with your therapist at any time. If you are dissatisfied with your therapy, we encourage you to first discuss the issue with your therapist. If you have any questions, complaints, or objections about the services that you receive, you have the right and your guardian has the right, to present grievances up to and including the provider’s executive director or comparable position. You or your guardian will be informed on how your grievances will be handled by the agency. A record of such grievances and the response to those grievances shall be maintained by CYFS. The Chief Executive Officer’s or designee’s decision on the grievance shall constitute a final administrative decision (except when such decisions are reviewable by the agency’s Board of Directors, in which case the Board of Directors’ decision is the final authority). If you want to discuss your concerns with someone other than your therapist, you may contact the therapist’s supervisor, at 217-352-5719. You will also be given a copy of The Center for Youth and Family Solutions Client Grievance Procedures.

You have the right to contact the following agencies regarding your case:

The Guardianship and Advocacy Commission
Equip for Equality, Inc. 431 E. Capital Avenue
427 East Monroe

Your service provider will help you in contacting these groups if you need assistance.

You have the right to contact the public payer or its designee and to be informed of the public payer’s process for reviewing grievances (the Department of Children and Family Services, the Department of Mental Health and Developmental Disabilities, or Healthcare and Family Services) as appropriate. Your service provider will help you in contacting them if you need assistance.

Information

If client is under 12, please have parent/ guardian complete:

Yes

Your Consent: I/We have read and understand the above information regarding the nature of therapy services rendered by The Center for Youth and Family Solutions Counseling Program. My rights have been explained to me in a language or method of communication that I/We can understand, I/We further understand that without my/our consent, such services cannot be rendered to me. By clicking Agree/Accept below, this indicates that I/we give full and informed consent to receive services from The Center for Youth and Family Solutions.

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