MEDICATION CONSENT FORM

Patient Name: _______________________________ DOB:________________

1. Medications are recommended for treating bothersome symptoms. The following symptom(s) I am
experiencing is/are the reason(s) my medication(s) is/are recommended for me:

Lack of energy or motivation

Depressed mood

Poor appetite or over eating

Difficulty concentrating or easily confused

Difficulty sleeping or sleeping too much

Anxiety or constant worrying

Difficulty coping with stress Irritability or agitation

Aggression or hostility

Mood swings

Rapid thoughts

Impulsive behaviors

Unwanted thoughts

Fixed beliefs

Fearful feelings or unrealistic fears

Visions or voices others can’t see or hear

Difficulty organizing thoughts

Difficulty communicating well with others

Hyperactivity

Panic attacks

Nightmares or flashbacks

Muscle stiffness or spasms

Restlessness
 Other: _______________

Medication Medication Type (Class Administration by Daily Dose (range) Frequency (Range)
name of Med) (Route)
□ Antidepressant □ □ Mouth □
Anti-Anxiety □ Injection □ Oher
Antipsychotic □ (specify):
Mood Stabilizer □
Psychostimulant □
Anti-EPSE □ Other
(specify):

THE FOLLOWING WAS EXPLAINED/PROVIDED TO ME:

 The foreseeable risk of using prescribed medication and diagnosis information.

 Administration of Treatment
 Alternative to treatment modes
 Consequences of not receiving proposed treatment
 I have been advised of the name, frequency, and potential side effects of the medications being
prescribed to me and how they can be controlled.
 Precautions regarding the use of other medications, alcohol/illicit drugs with these prescribed
medications .
 Proper storage of the medications .
 The benefits expected from using these medications .
 The available alternative, if any, and how they can be controlled.
 The complications, if any, related to prolonged use of the medication .
 How and why to take the medication.
 Who to contact if I have any questions regarding the medications prescribed .
 My need for this medication will be evaluated every visit. It is common to continue taking
medications after the symptoms have gone away to prevent the symptoms from coming back. It
is estimated that I will be prescribed these medications for at least: 6 months, 12 months or….
 Additional and alternative treatment options deemed reasonable for my condition include:

…..Psychotherapy …….. Group or family therapy … Other medications .. Other:____________

 I have been advised that if I am of Child Bearing Age to avoid becoming pregnant while taking
psychotropic medication, and to notify my psychiatrist immediately upon becoming pregnant.
 Lab tests or other assessments performed at least once a year to monitor my progress and risk
of experiencing side effects
 I have been offered and discussed medication information to my satisfaction and understand
the importance of above mentioned points.
  I have been offered a copy of this medication consent form and understand I have the right to
ask for additional medication information, refuse to take medication(s) and I may withdraw this
consent at any time.
 I give my consent on………………(write date) for psychiatrist to prescribe medications for
………(write patient's name)

Client’s or Substitute Decision Maker’s Signature: ……………Relationship to Client:……….. Date:

………………….

Prescriber’s Signature:

□ Psychiatrist (MD/DO)

□ Psychiatric Nurse Practitioner (PNP)

□ Physician Assistant (PA)

Date:

Staff Witness Name & Signature:……….. Date: ………………….

____________________________________________ ________________________________
Patient’s Signature Date

____________________________________________ ________________________________
Parent/Guardian Signature Date

(Patients 12 to 18 must sign in addition to the parent)