Form Dd-162 - Consent For Use Of Behavior-Modifying Medications With A Behavior Treatment Plan Page 2
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4DD-162 (6-06) – Page 2
SIGNATURE PAGE (Please sign and date the appropriate section and return it to your DDD Case Manager.)
SECTION I
I, the undersigned, have received and understand the information on the previous page concerning the expected results and side effects
pertaining to the use of ________________________________________________________________________________________,
(Medication)
with a maximum dosage of ______________________________________________________, for a period not to exceed 12 months.
I hereby give my consent to the use of this medication for ____________________________________________________________.
(Client’s Name)
CLIENT/RESPONSIBLE PERSON’S SIGNATURE
DATE
SECTION II
I, the understand, have reviewed the need for a behavior-modifying medication for _________________________________________
(Client’s Name)
_________________________________________________ and DO NOT give my consent for the administration of this medication.
My reason for refusing to give consent is __________________________________________________________________________
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CLIENT/RESPONSIBLE PERSON’S SIGNATURE
DATE
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