Form DOC13-386 "Consent for Evaluation and Initiation of Mental Health Treatment" - Washington

What Is Form DOC13-386?

This is a legal form that was released by the Washington State Department of Corrections - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 21, 2019;
  • The latest edition provided by the Washington State Department of Corrections;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOC13-386 by clicking the link below or browse more documents and templates provided by the Washington State Department of Corrections.

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Download Form DOC13-386 "Consent for Evaluation and Initiation of Mental Health Treatment" - Washington

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PATIENT I.D. DATA:
(Name, DOC#, DOB)
CONSENT FOR EVALUATION AND INITIATION OF MENTAL HEALTH TREATMENT
I.
The Department of Corrections (DOC) offers mental health evaluations or treatment to patients needing
services (see Policy Directive DOC 630.500, Mental Health Services).
II.
You have the following rights whether or not you consent to evaluation or treatment:
 You generally have a right to refuse evaluation and treatment (including medications) at any time.
However, if health care staff determine that you are an immediate risk to harm yourself or others or if you
meet other requirements (see Policy Directive 630.540, Involuntary Antipsychotic Administration and
Policy Directive DOC 610.010, Consent for Health Care), you may be given an evaluation and/or
treatment (including medications) against your will.
 If you elect to refuse recommended mental health evaluation or treatment, you will be informed of
possible risks of refusing services (DOC form 13-048).
 You have a right to review, ask questions about, and offer suggestions related to your mental health
treatment. Your suggestions may or may not be followed.
 You have a right to make a complaint about your mental health evaluation or treatment either to the local
Correctional Mental Health Program Manager (CMHPM) or other staff member in charge of mental health
if you are not able to resolve the issue with your provider or through a grievance process. NOTE: You
must try to resolve the issue with your provider or his/her supervisor before going to the local mental
health staff member who is in charge.
 You have a right to review your mental health records, unless there is a clinical reason to prohibit this
review. This request must be in writing.
You have a right to inquire as to the qualifications of your provider to render a specific treatment.
III.
You should be informed about the following before starting a mental health evaluation or treatment (see
Policy Directive DOC 610.010, Consent for Health Care):
 The nature of and reason for the proposed evaluation or treatment.
 What options you may have other than the recommended treatment.
 The possible risks and benefits of the recommended evaluation or treatment and of other options you
may choose (including no treatment).
NOTE: Informed consent does not mean that you are consenting to release information.
It is important to know that there are times when some information about your mental health may be
disclosed to others without your consent. This is only done in accordance with state and federal laws and
DOC policies and is limited to the amount necessary to meet the legal or policy requirement.
CONSENT
Place an X in the box next to the statement that applies to you:
Yes
No
1.
*
I have been informed about my rights to consent or not to consent to evaluation or treatment.
2.
*
I agree to receive and participate in a mental health evaluation at this time.
3.
*
I agree to receive and participate in mental health treatment at this time.
Specify treatment:
My signature below means that I have read or had explained to me the information on this form. I have asked
questions about anything that was not clear to me. I understand the information and the checked boxes are
correct.
SIGNATURE OF PATIENT/Surrogate decision maker
DATE
SIGNATURE/STAMP OF MENTAL HEALTH PROVIDER
DATE
The patient refused to sign this form. The marked boxes above indicate statements that apply to the patient.
For Provider Use Only:
*If No to 2 or 3:
The provider reviewed or attempted to review the Refusal of Treatment form (DOC 13-048) with the
patient
The patient chose not to sign the Refusal of Treatment form (DOC 13-048)
State law and/or federal regulations prohibit disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
DOC 13-386 (11/21/2019)
DOC 610.010
LEGAL: Consents/Agreements
Data classification category 1
PATIENT I.D. DATA:
(Name, DOC#, DOB)
CONSENT FOR EVALUATION AND INITIATION OF MENTAL HEALTH TREATMENT
I.
The Department of Corrections (DOC) offers mental health evaluations or treatment to patients needing
services (see Policy Directive DOC 630.500, Mental Health Services).
II.
You have the following rights whether or not you consent to evaluation or treatment:
 You generally have a right to refuse evaluation and treatment (including medications) at any time.
However, if health care staff determine that you are an immediate risk to harm yourself or others or if you
meet other requirements (see Policy Directive 630.540, Involuntary Antipsychotic Administration and
Policy Directive DOC 610.010, Consent for Health Care), you may be given an evaluation and/or
treatment (including medications) against your will.
 If you elect to refuse recommended mental health evaluation or treatment, you will be informed of
possible risks of refusing services (DOC form 13-048).
 You have a right to review, ask questions about, and offer suggestions related to your mental health
treatment. Your suggestions may or may not be followed.
 You have a right to make a complaint about your mental health evaluation or treatment either to the local
Correctional Mental Health Program Manager (CMHPM) or other staff member in charge of mental health
if you are not able to resolve the issue with your provider or through a grievance process. NOTE: You
must try to resolve the issue with your provider or his/her supervisor before going to the local mental
health staff member who is in charge.
 You have a right to review your mental health records, unless there is a clinical reason to prohibit this
review. This request must be in writing.
You have a right to inquire as to the qualifications of your provider to render a specific treatment.
III.
You should be informed about the following before starting a mental health evaluation or treatment (see
Policy Directive DOC 610.010, Consent for Health Care):
 The nature of and reason for the proposed evaluation or treatment.
 What options you may have other than the recommended treatment.
 The possible risks and benefits of the recommended evaluation or treatment and of other options you
may choose (including no treatment).
NOTE: Informed consent does not mean that you are consenting to release information.
It is important to know that there are times when some information about your mental health may be
disclosed to others without your consent. This is only done in accordance with state and federal laws and
DOC policies and is limited to the amount necessary to meet the legal or policy requirement.
CONSENT
Place an X in the box next to the statement that applies to you:
Yes
No
1.
*
I have been informed about my rights to consent or not to consent to evaluation or treatment.
2.
*
I agree to receive and participate in a mental health evaluation at this time.
3.
*
I agree to receive and participate in mental health treatment at this time.
Specify treatment:
My signature below means that I have read or had explained to me the information on this form. I have asked
questions about anything that was not clear to me. I understand the information and the checked boxes are
correct.
SIGNATURE OF PATIENT/Surrogate decision maker
DATE
SIGNATURE/STAMP OF MENTAL HEALTH PROVIDER
DATE
The patient refused to sign this form. The marked boxes above indicate statements that apply to the patient.
For Provider Use Only:
*If No to 2 or 3:
The provider reviewed or attempted to review the Refusal of Treatment form (DOC 13-048) with the
patient
The patient chose not to sign the Refusal of Treatment form (DOC 13-048)
State law and/or federal regulations prohibit disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
DOC 13-386 (11/21/2019)
DOC 610.010
LEGAL: Consents/Agreements
Data classification category 1