Domestic Abuse Treatment Consent Form

Domestic Abuse Treatment Consent Form

Patient Information

Patient Name:

Date of Birth:    Gender: Female Male Non-binary Prefer not to say

Insurance / Billing

Medical & Social History

Incident Information (Optional)

Suspected Perpetrator Relationship:

Date of Most Recent Incident:

Are there current visible injuries? Yes No

Consent to Treatment and Services

I consent to receive services related to domestic abuse including medical evaluation, counseling, safety planning, and referrals. I understand that the services I may receive include the following (select all that apply):

Medical evaluation and treatment
Forensic/sexual assault evidence collection (when applicable)
Crisis counseling and short-term psychotherapy
Safety planning and risk assessment
Referral to community advocacy and support services
Medication evaluation and management
Other services

Risks, Benefits, and Alternatives

Benefits of receiving the services described above may include treatment of injuries, documentation of injuries, improved physical and emotional safety, connection to resources, and assistance in planning for safety. Potential risks include emotional distress when discussing traumatic material, possible involvement of law enforcement or legal systems depending on circumstances, and collateral notification if required by law. Alternatives to these services include declining treatment or seeking services elsewhere.

Confidentiality and Limits

Information obtained in the course of treatment is confidential and will not be disclosed without my written authorization except as required or permitted by law. Exceptions include: mandatory reporting of child abuse or elder abuse; disclosure required to prevent a clear and imminent danger to self or others; disclosures pursuant to a valid court order or subpoena; and where reporting is required by statute in relation to certain types of violent injury. Information necessary to coordinate care among providers involved in my treatment may be shared with my care team unless I specifically restrict such disclosures in writing.

Authorization to Share Information

I authorize the provider to share relevant medical and safety information about me with the following individuals and organizations as needed to provide care, to coordinate services, or to ensure safety (check all that apply):

Domestic violence advocate/support agency
Other medical providers involved in my care
Social services or housing programs
Law enforcement (when required or requested for safety)
Legal counsel (with written consent)

This authorization expires on:    I understand I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on this authorization.

Voluntary Consent and Acknowledgment

I have been informed of the nature and purpose of the proposed evaluation and services, the potential risks and benefits, the limits of confidentiality, and alternatives to treatment. I have had the opportunity to ask questions and my questions have been answered to my satisfaction.

I acknowledge that I understand the above information and consent to participate in the indicated services.

Interpreter and Special Needs

Do you require an interpreter or communication assistance? Yes No

Patient Rights

I understand that I may refuse or discontinue any service at any time. I understand how to raise concerns, complaints, or grievances regarding my care and that doing so will not affect my access to services. I understand that I have the right to receive a copy of this signed consent upon request.

Acknowledgment of Receipt of Privacy Notice

I acknowledge that I have received and been offered an explanation of the organization's privacy practices and patient rights related to protected health information.

Sign Now