Psychiatric Treatment Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ________________ Date: _________________________

1. Consent for Treatment

I, _________________________, voluntarily consent to receive psychiatric services from [Practice Name], including:

• Psychiatric evaluation and diagnosis
• Medication management
• Psychotherapy
• Other treatments deemed necessary by my provider

2. Nature of Psychiatric Treatment

• I understand that my treatment may include various therapeutic approaches
• Treatment recommendations will be discussed with me
• Medication options, if prescribed, will be explained including:
  • Expected benefits
  • Possible side effects
  • Alternative treatments
  • Risks of non-treatment

3. Confidentiality

I understand that:

• My health information is protected under HIPAA
• Information will only be released with my written consent except when:
  • There is suspected abuse of a child, elderly, or disabled person
  • There is an imminent threat to self or others
  • Required by law or court order

4. Emergency Procedures

• In case of emergency, call 911 or go to the nearest emergency room
• After-hours contact procedures: _________________________________

5. Financial Agreement

• I understand I am responsible for payments not covered by insurance
• Cancellation policy requires ____ hours notice
• No-show fee: $_______

6. Acknowledgment

I have read and understand this consent form. My questions have been answered to my satisfaction.

Patient/Guardian Signature: _________________ Date: ____________ Provider Signature: _______________________ Date: ____________

7. Consent Renewal

This consent is valid for one year from the date of signing unless revoked in writing.