Psychiatric Practice Communication Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Chart Number: __________________ Date: _________________________

Communication Preferences and Authorization

I, _________________________, authorize [Practice Name] to communicate with me using the following methods (please initial all that apply):

___ Voice messages at phone number: ____________________

• □ Detailed messages allowed
• □ Brief messages requesting callback only

___ Text messages at phone number: ____________________

• □ Appointment reminders only
• □ Brief clinical messages
• □ Prescription notifications

___ Email at address: ________________________________

• □ Appointment information
• □ Clinical summaries
• □ Patient portal registration
• □ Educational materials

Emergency Communication Protocol

I understand that:

• These communication methods are not appropriate for emergencies
• For urgent matters, I should call the office directly
• For emergencies, I should dial 911 or go to the nearest emergency room

Privacy Acknowledgment

I acknowledge that:

1. Electronic communications may not be secure
2. Messages may be viewed by office staff
3. Communications will become part of my medical record
4. I can revoke this consent at any time in writing

Signature

Patient/Guardian Signature: _____________________ Date: __________

Print Name: ___________________________ Relationship to Patient: ____________

Practice Representative: _________________ Date: __________