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Informed Consent for Treatment
with Psychotropic Medications
Please read and sign the form below.
Download the form to obtain Physician and other needed signatures here: Informed Consent for Treatment with Psychotropic Medications
Informed Consent for Treatment with Psychotropic Medications
am currently a patient of Dr.
and am receiving care at House of Hope for Girls Program. My doctor has recommended that I receive a psychotropic medication,
to assist in my treatment.
This medication is classified as a
and is used in the treatment of .
I have been given an opportunity to discuss the risks and benefits of the medication treatment, common medication side effects and alternative treatments.
I agree to take the medication as prescribed, report any and all side effects and concerns about the medication promptly to my doctor, nurse, or program staff and to seek out additional information and ask questions so that I can remain an informed patient.
I agree to not give my medication to any other participant and understand that it is solely prescribed to me and for my treatment alone.
I understand that I am taking this medication voluntarily unless my doctor feels that an emergency is at hand and any delay in receiving the medication could likely result in harm to myself, those around me or tot property. I further understand that I may speak directly with the doctor treating me regarding my medication if I have any questions or concerns. I also understand that this medication is designed to help me but that no guarantees of successful results can be made.
On this basis, I am making an informed consent to take this medication as prescribed and agree to allow my doctor, his or her designee or the residential staff to administer the medication to me as ordered by my physician.
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