Psychiatric Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date of Birth: _____________ Date: _________________________ Chart Number: _____________

Agreement Terms

1. Consent for Treatment

I, _________________________, agree to receive psychiatric services from Dr. _________________________ which may include:

• Psychiatric evaluation and diagnosis
• Medication management
• Psychotherapy
• Other recommended treatments: _________________________

2. Confidentiality

I understand that:

• All information shared is confidential with exceptions required by law
• Confidentiality may be broken if there is:
  • Imminent danger to self or others
  • Suspected abuse of children, elderly, or disabled persons
  • Court order requiring information disclosure

3. Medication Management

I agree to:

• Take medications as prescribed
• Inform the provider of all other medications and supplements
• Not share or sell prescribed medications
• Notify the provider of any side effects or concerns
• Submit to drug screening if requested

4. Appointments and Communication

I understand that:

• 24-hour notice is required for appointment cancellation
• Emergency services are available through local emergency rooms
• Response time for non-urgent matters may be up to 48 hours
• Missed appointments may result in termination of care

5. Financial Responsibility

• Payment is expected at time of service
• Insurance information must be current
• Copays and deductibles are patient responsibility

Signatures

Patient Signature: _________________________ Date: _____________

Provider Signature: _________________________ Date: _____________

Witness Signature: _________________________ Date: _____________