Psychotropic Medication Consent

Patient Name*

First Last

Patient Date of Birth*

Is the patient 18 or older?*

Yes
No

Drug Name*

Your psychiatrist/psychiatric nurse practitioner would like to begin/continue this medication to help you with the following problems:*

Reduce hearing voices and bizarre thinking
Reduce impulsive and aggressive behavior
Reduce Acute Mania
Other

Explain other problem*

If you experience any of these side effects or any other unusual feelings, please call the office at (860) 437-4550. If the concern is severe enough, please proceed to the closest emergency room.

*Please be advised that discontinuing some of these medications abruptly can result into problematic side effects or recurrence of original symptoms.

Off label Acknowledgement*

I have been made aware that prescriptions for children and adolescents may be “off-label,” meaning that pharmaceutical companies have not sought FDA approval to market medications for the treatment of youths.

Treatment Acknowledgment*

I understand that treatment will be monitored by me as well as the provider and that I will have access to the provider if I have questions or my child has problems with the medication

Side Effect Acknowledgement*

The provider has reviewed the above possible side effects with us and we understand that we have the right to refuse or discontinue medications, but agree to discuss this with our provider first.

Consent Form Acknowledgement*

We were provided a copy of this consent form.

Parent/Guardian Signature*

Patient Signature*

Email*

Today's date*

Medication Consent-Psychotropic

Psychotropic Medication Consent

Please click SUBMIT when complete