"*" indicates required fields HiddenDate MM slash DD slash YYYY Under Minnesota Statutes §245G.15, clients have the right to make informed decisions regarding their treatment, including the right to decline specific services. Minnesota Statute under the 1115 waiver requires an individual receiving 245G SUD treatment to have a diagnostic assessment completed within 10 days of treatment initiation when the GAIN-SS mental health symptom screener is positive at intake. This form documents your decision to decline a mental health diagnostic assessment as part of your treatment at this facility.Client InformationClient Name* First Last Client Date of Birth* MM slash DD slash YYYY Client Email Elite Recovery Staff*Select MH ClinicianAnna JensenAnna LipinskiBetsey DegreeDelaney AndersonDietrich AndersonErin MalkowKarla SelnessLulu SveenPatrick JohnsonPaula NoonanSpencer MelbyTaharah HoveyTegan SmischneyOtherDiagnostic Assessment AcknowledgementDeclining a Diagnostic Assessment Acknowledgement*Please review and acknowledge your agreement with the following process and terms.I acknowledge that: 1. I have been informed of the purpose and nature of the diagnostic assessment as outlined in Minnesota Statutes and the 1115 Waiver. 2. I understand that the assessment is designed to evaluate my mental health needs to develop an appropriate treatment plan. 3. I am aware that declining the assessment may impact the ability of the treatment team to provide services tailored to my specific needs. 4. I have had the opportunity to discuss any questions or concerns with my counselor or another qualified staff member. 5. I retain the right to consent to the assessment at any future point during their treatment. 6. I am making this decision voluntarily and without coercion. I acknowledge and agree with the above statement. Signature*By signing below, I am authorizing the declination of a mental health diagnostic assessment at this time. I understand the potential implications of this decision on my treatment and acknowledge that I may request the assessment at a later date.Authorization to Reference Previous Diagnostic AssessmentAcknowledgment I acknowledge that Elite Recovery has received a previously completed Diagnostic Assessment from another facility, and I understand that this assessment will be utilized in treatment planning and clinical decision-making, in accordance with DHS guidelines. Name of facility where most recent DA was completed: Date* MM slash DD slash YYYY
