Psychiatry Informed Consent

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PSYCHIATRY Informed Consent
Today's Date:*
Date Format: MM slash DD slash YYYY
Client/Patient Name*
First Last
Client/Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Email*
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.
I acknowledge*
Choices Psychotherapy Notice of Privacy Practices with an effective date of: 9/23/2013.
Client/Patient Signature (Please Type)*
Signature of Client/Patient or Parent/Guardian (Please Type)
Description of guardian’s authority and relationship to client:
Today's Date:
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

p: 952.544.6806

Psychiatry Informed Consent

PSYCHIATRY Informed Consent

Receipt of Privacy Practices

Choices Psychotherapy

Office: 952-544-6806

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