Psychiatric Treatment Agreement and Informed Consent

Patient Information

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

1. Consent for Treatment

I, ______________________, voluntarily consent to receive psychiatric evaluation and treatment from Dr. ______________________ and associated clinical staff. I understand that I may discontinue treatment at any time.

2. Treatment Understanding

• Mental health treatment may include:
  • Psychiatric evaluation and diagnosis
  • Medication management
  • Psychotherapy
  • Laboratory studies as indicated
  • Coordination with other healthcare providers

3. Confidentiality Agreement

I understand that:

• All communications with my provider are confidential
• Information will only be released with my written consent
• Exceptions to confidentiality include:
  • Risk of harm to self or others
  • Suspected abuse of children, elderly, or disabled persons
  • Court orders
  • Insurance billing requirements

4. Medication Management

If prescribed medications, I agree to:

• Take medications as prescribed
• Report side effects promptly
• Not discontinue medications without consultation
• Inform provider of all other medications/supplements
• Submit to drug screening if requested

5. Appointments and Communication

I agree to:

• Attend scheduled appointments
• Provide 24-hour notice for cancellations
• Pay applicable no-show fees
• Use the patient portal for non-urgent communication
• Call 911 or go to nearest ER for emergencies

6. Financial Agreement

• I understand I am responsible for payments/copays
• I will maintain current insurance information
• I authorize insurance billing

Signatures

Patient: _________________________ Date: _____________ Provider: ________________________ Date: _____________ Witness: _________________________ Date: _____________