Informed Consent For Psychiatric Medications

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Santa Cruz County Mental Health & Substance Abuse Services
1400 Emeline Avenue, Building K, Santa Cruz, CA 95060
Phone: 1 (800) 952-2335
Fax: (831) 454-4484
Informed Consent for Psychiatric Medications
Client Name:
County I.D. #:
Purpose of the form:
This form documents that you and your doctor have discussed your medicines to your satisfaction.
Your psychiatrist/nurse practitioner has prescribed the following medication(s). Your psychiatrist/nurse practitioner has either told you about the
medications, or given you written information, or both. You are entitled to know the following information before deciding whether to take the medication:
1.
What your condition or diagnosis is.
2.
What symptoms the medications should reduce and how likely the medications are to work.
3.
What your chances are of getting better without the medications.
4.
What other reasonable treatments are available.
5.
The name, dosage, frequency, route of administration and duration of prescribed medications.
6.
Any special instructions about taking the medications.
7.
The probable side effects of these medications known to commonly occur, and any particular side effects likely to occur in your particular case.
8.
Additional side effects may occur if you take medications beyond three months. These side effects include tardive dyskinesia, which may persist after
the medication has been discontinued.
9.
The ability to drive, operate machinery, or other skilled tasks may be impaired by medications. Alcohol or illicit drugs may worsen this effect.
10. If you are pregnant, plan to become pregnant, or are breastfeeding, your psychiatrist should be notified. Medications may pose known or unknown
risks to the fetus or infant.
.
11. Any special instructions about taking the medications
Medication
Route
Dose
Frequency
Max Daily Dose
By signing this form, you indicate the medications have been explained to you to your satisfaction.
Even after signing, you can still refuse any dose or withdraw your agreement completely at any time.
You will receive a copy of this consent form.
Please check one of the following:
I have had the opportunity to receive written and verbal information about the medications with the psychiatrist/nurse practitioner, and I
consent to this treatment. I understand I can ask questions about my medications at any time. (INFORMED CONSENT)
I have had the opportunity to discuss information about the medications with the psychiatrist/nurse practitioner, and I refuse to consent
to the medications recommended. I understand that psychiatry staff will continue to offer me the chance to take medicine, and
information about it, but that I may still continue to refuse the medicine. (INFORMED REFUSAL)
Psychiatrist/Nurse Practitioner only:
The patient verbally consents to the recommended medications, but refuses to sign because: ______________________
____________________________________________________________________________________________________
Continued attempts to obtain signature: Initials: ________Date: __________ | Initials: ________ Date: __________ | Initials: ________ Date: ___________
Patient Signature:
Date
Psychiatrist/Nurse Practitioner Name (PRINT):
Psychiatrist/Nurse Practitioner Signature:
Date:
Witness Name if patient unable or unwilling to sign (PRINT):
Witness Signature:
Date
Parent / Legal Guardian / Conservator Name (PRINT):
Parent / Legal Guardian / Conservator Signature:
Date:
MHE 702
Distribution: Original in Chart; Copy to Parent or Legal Guardian, Copy to Public Guardian (if conserved)
Rev 3-2015

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