General Information: You can expect the attention, respect, and best professional efforts of your Mental Health Clinic (MHC) provider and staff. Your provider will treat you as a responsible individual and will expect you to take part in treatment decisions. You should understand the goals of therapy and the direction it is taking. If you do not understand, you should ask. If you are dissatisfied with your care, you have the right to request a different provider or a second opinion from another MHC provider. Both of these rights can be exercised by informing any member of the MHC staff. Federal law and military regulations govern the privacy of information you discuss with your MHC provider. Some kinds of information may be released without permission. If you do not understand your privacy in this setting, discuss it with your provider before beginning an evaluation or treatment.

Disclosure Policy: Most information related to treatment is not releasable without the written consent of the client. Excluded from consent are such activities as quality assurance reviews by other mental health professionals and collection of information for medical research and official authorized military investigations. Release or disclosure to anyone else generally requires your written consent. Exceptions are discussed below.

Access by Commanders: Commanders with a justifiable military need to know information on a military member may obtain it without the member's authorization. Such information includes, but is not limited to duty restrictions, medical conditions warranting a Medical Evaluation Board, conditions that affect reliability for PRP, FLY, or Controlling duties, suicide attempts or serious intent, inpatient hospitalization, and some duty impairing conditions warranting administrative discharge. At times the commander may receive the information via the first sergeant for enlisted members.

Drug and Alcohol Abuse: Military providers must report drug/alcohol abuse in active duty members to commanders and are required to refer these members to the Alcohol and Drug Abuse Prevention and Treatment Program (ADAPT) for evaluation. The Office of Special Investigations (OSI) is contacted for drug abuse cases. An Air Force member may voluntarily disclose evidence of personal drug use or possession to the unit commander, first sergeant, substance abuse evaluator, or a military medical professional. Commanders will grant limited protection for Air Force members who reveal this information with the intention of entering treatment. Commanders may not use voluntary disclosure against a member in an action under the Uniform Code of Military Justice (UCMJ) or when weighing characterization of service in a separation. Disclosure is not voluntary in certain instances IAW AFI 44-121. If you have questions or concerns, please consult with your provider or the Area Defense Council (723-3405) prior to disclosure.

UCMJ Violations: These are reportable and include, but are not limited to fraud, adultery, homosexual behaviors, AWOL, desertion, and other crimes unique to the military.

Medical Evaluation Boards: Chronic conditions or conditions not expected to fully remit after a maximum of twelve (12) months will be referred to a medical evaluation board.

Child/Spouse Abuse: Providers must report child abuse, suspected child abuse or child neglect, and incidents of spouse abuse or other family violence to military agencies and/ or local child protective authorities.

Serious Criminal Offenses: State and federal laws require disclosure of some serious crimes, threat, or intent to commit such crimes by patients. Such crimes include homicide, intent to commit acts of violence, and sex offenses.

Suicide: Providers have a legal and ethical obligation to prevent suicide and aid the individual with regaining the will to live. To this end, providers may consult with other providers. They may also consult the Judge Advocate General (JAG) in cases where the individual is no longer cooperative in maintaining his or her own safety and legal avenues are needed to prevent death.

Limited Privilege Suicide Prevention Program (LPSP): This program provides limited confidentiality in the event you have been notified of a commander's intent to impose punishment pursuant to Article 15, UCMJ or you have courts martial charges preferred against you pursuant to Article 30, UCMJ. If either of these conditions applies to you, you may be eligible for enrollment in this program and should request additional information from your provider.

Records of Your Care: Every patient visit to the MHC is documented in the outpatient medical record (OPR). Only entries necessary for quality care are made in the OPR. These notes are kept to a minimum to maintain your privacy. We try to balance your reasonable exceptions of privacy against a possible need for information during future care. The more detailed notes necessary for your individual care, are maintained in a MHC record. The MHC record is stored in the MHC under lock and key.

Do you desire and consent to have a family member contacted and involved in your treatment 0 Yes 0 No (initial).
If yes, provide name, relationship and phone number.


I have read and understand the above policies. I understand that I may have the information above explained to me and that a signed copy of this form will be given to me at my request. By signing this form I am freely consenting to be evaluated.

Patient Signature