Healthcare Behavior Contract

HEALTHCARE BEHAVIOR CONTRACT

Parties and Effective Date

Patient Name:

Date of Birth:    Record Number/ID:

Effective Date of Plan:    Plan Duration (weeks/months):

Patient Contact Information

Emergency Contact

Insurance Information

Behavioral Goals and Measurable Objectives

Targeted Behavior(s):

Measurable Goals (include baseline and target metrics):

Interventions, Supports, and Restrictions

Selected Interventions (check all that apply):

Positive reinforcement and incentives    Behavioral therapy techniques    Environmental modifications

Medication management (as prescribed)    Crisis management / de-escalation procedures    Other (see description)

Consequences, Safety Measures, and Crisis Plan

Consequences for continued noncompliance or escalation (behavioral responses and agreed steps):

Crisis Plan: triggers, immediate de-escalation steps, who will be notified, and thresholds for emergency services:

Consent to contact emergency services if patient presents imminent risk: I consent

Responsibilities and Rights

Patient Responsibilities: The patient agrees to participate in the interventions described above, to communicate changes in condition or response to treatment, and to follow scheduled appointments and prescribed recommendations. Failure to comply may result in modification of services or discharge in accordance with provider policy.

Provider Responsibilities: The treatment team will implement documented interventions to the extent clinically appropriate, will monitor progress, and will review and revise this plan as necessary. Providers will document incidents and will seek to minimize use of restrictive measures.

Right to Modify or Withdraw: The patient may request modification or withdrawal of consent. The provider may modify or suspend aspects of this plan if the patient poses an imminent risk to self or others, subject to clinical judgement and applicable law.

Confidentiality and Information Sharing

Information about this plan and related clinical records will be maintained in the patient's health record in accordance with privacy regulations. Information may be shared with designated individuals and other treatment providers as necessary to implement the plan or when disclosure is required by law (including imminent risk situations). By signing below the patient authorizes appropriate disclosures to implement this plan and coordinate care.

Authorization Expiration Date:

Monitoring and Review

Review Schedule: The plan will be reviewed on the following dates. First review: ; Subsequent reviews as clinically indicated.

Acknowledgments and Consents

By initialing and signing below, the patient acknowledges that they have discussed the behavior plan with their treatment team, understand the goals and interventions, and consent to implementation of the plan as described below. The patient acknowledges receipt of a copy of this plan upon request.

I agree to participate in and comply with this plan: Yes

I understand I may withdraw consent except where clinical judgment or law requires continued care: Yes

Signatures

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