Psychotropic Medication Authorization

Psychotropic Medication Authorization Form

Client/Parent/Legal Guardian (Print) :

Relationship to Recipient:

Phone Number: (Home):

Cells:

I consent to the use of the psychotherapeutic medication(s) listed above.

I do not consent to the psychotherapeutic medication(s) listed above.

Comments:

Signature of Parent/Legal Guardian:

تم تحديد وضع الرسم. يتطلب الرسم استخدام الماوس أو لوحة اللمس. لإمكانية الوصول إلى لوحة المفاتيح، حدد كتابة أو تحميل.

Date

Section A – Psychotropic medication recommendation:

(to be completed by licensed medical professional)

PT ID#:

Client’s name:

Date of Request:

Date of birth:

All current Psychotherapeutic Medication:

Medication/dosage/ administration schedule-1

Medication/dosage/ administration schedule-2

Medication/dosage/ administration schedule-3

Medication/dosage/ administration schedule-4

Psychotropic medication discontinued:

New medication and recommendation: (does not include dosage changes)

Potential side effects reviewed with child:

Yes

Medication Handout provided:

Yes

Informed Consent:

By my signature below, I GIVE consent for the named medication above and anticipated dosage range. My signature also indicates that I understand the following:

I have been educated about the nature of the treatment and potential benefits, risk, side effects, warnings, and cautions associated with the medication(s) prescribed.
I understand that although the most common side effects of the medication(s) have been explained to me, there may be other side effects and I should promptly inform the physician or nursing staff if there are any unexpected changes in my condition.
I have had the opportunity to discuss the reason for this prescribed psychotropic medication, the expected outcome(s), the approximate length of treatment and how the medication will be monitored. I have had the opportunity to discuss alternative treatments available. I have also had the opportunity to discuss the benefits and risks of this medication, including the possible side effects, the potential medication interactions and the potential effects of stopping the medication. I have had an opportunity to ask questions and have my questions answered.
I can refuse to give consent or can withdraw my consent at any time with written notification to the institution director or designee. This will not affect my right to change my decision at a later date. If I withdraw consent after a medication is started, I realize that the medication may not be discontinued immediately. Rather, it will be tapered as rapidly as medically safe and then discontinued so as to prevent an adverse medical consequence, such as seizures, due to rapid medication withdrawal.