Authorization for Psychiatric Treatment and Services

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Treatment

I, _________________________, hereby authorize [Practice Name] and its mental health professionals to provide psychiatric evaluation, treatment, and services. I understand this may include:

• Psychiatric diagnostic evaluation
• Medication management
• Psychotherapy
• Psychological testing (if indicated)
• Telemedicine services (when applicable)

Treatment Understanding

1. I understand that my treatment plan will be discussed with me and may be modified as needed.
2. I acknowledge that no guarantees have been made about the results of treatment.
3. I understand the importance of providing accurate information about my medical history, medications, and symptoms.

Confidentiality Statement

I understand that my health information is protected under HIPAA regulations and will be kept confidential except in the following circumstances:

• Risk of harm to self or others
• Suspected abuse of children, elderly, or disabled persons
• Court order or legal requirement
• Insurance billing purposes (limited information)

Financial Agreement

I understand that I am responsible for:

• Payment of all charges not covered by insurance
• Providing current insurance information
• Notifying the office of any changes in my insurance coverage

Medication Management (if applicable)

I agree to:

• Follow prescribed medication regimens
• Attend scheduled medication management appointments
• Inform the provider of any side effects or concerns
• Request refills during regular office hours with 72 hours notice

Signatures

Patient Signature: _________________________ Date: _____________

Guardian Signature: ________________________ Date: _____________ (If patient is a minor or unable to consent)

Provider Signature: _________________________ Date: _____________

Witness: __________________________________ Date: _____________