Notice of Privacy Practices

Breakthrough Christian Counseling and Alternative Education Center, LLC (the “Practice”) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice’s legal duties and privacy practices and your rights regarding PHI that we collect and maintain.

Consent for Services

By signing this document, you agree to allow yourself/your child to enter the Breakthrough program. You have the right not to sign this form. Your signature indicates you have read and discussed this agreement; it does not indicate that you are waiving any of your (child’s) rights. You can choose to discuss concerns with the counselor before you/my child begins therapy. You have the right to withdraw your consent to your (child’s) therapy at any time, for any reason. Breakthrough asks that you make every effort to discuss any concerns with the therapist or Breakthrough administration before ending the treatment program. Violation of Breakthrough policies may result in the termination of your (child’s) services.

Minor Assent Form

During the intake session your therapist will read the “Minor Assent Form” out loud to all attendees. The minor assent form is for youth to understand their rights as a minor client. Please let your therapist know if you have any questions or concerns regarding this document.