logo
p: 952.544.6806
 

Psychiatry Informed Consent

  • PSYCHIATRY Informed Consent

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Your signature indicates that you are being seen (or your child is being seen) voluntarily. You are consenting to the Psychiatric evaluation that you or your child has been scheduled and this session along with all subsequent sessions may include medication management and/or psychotherapy.
    In the course of your treatment at this clinic you may be prescribed medication. If this occurs, it may be necessary to share this information with your pharmacy by facsimile, mail or phone to facilitate the filling of the prescription or refills. If prior authorization is needed by your insurance company to cover your medication, it may also be necessary to share your information with them.
    If you use a transportation service to come to your appointment it may be necessary to verify that you were here for your appointment with that transportation service.
    In addition to consent for treatment your signature below acts as a release and authorization to share this information in the manner described above.
  • Receipt of Privacy Practices

  • This is to acknowledge receipt of a copy of the Choices Psychotherapy Notice of Privacy Practices with an effective date of: 9/23/2013.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.