Consent for Psychiatric Services

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Name:     Date of Birth:

Consent for Psychiatric Services

Entry & Assessment

  • My request for services from CFD is voluntary.
  • I may ask questions at any time.
  • As part of my request for services at Center for Family Development (CFD), I authorize clinical staff to complete an evaluation and provide medication services, if needed.
  • Information that is discussed during the psychiatric evaluation is confidential and no information about my case can be released to anyone outside CFD's MAT services without written authorization from me except as noted in the Release of Information section below.

Plan for Treatment

  • I will be involved in the creation of a plan for treatment and will continue to be involved in changes made throughout the duration of services with CFD.


  • I may access my medical provider's immediate supervisor upon my request should I experience concerns or wish to express a grievance.
  • My medical provider and their supervisor will keep my information confidential.

Therapeutic Privilege

  • I am the holder of privilege within the therapeutic setting. Information that is discussed during services is confidential and no information about my case can be released to anyone outside CFD without written authorization from me, except as stated below.
  • My medical provider and I are prohibited from recording sessions without written permission, signed by both me and my medical provider.

Mandatory Reporting

  • If I reveal past or threatened abuse of a person who is in a protected category, whether that person is myself or another individual, CFD staff must disclose and report such information as required by Oregon law. Individuals in the protected categories are children, elderly persons, developmentally disabled persons, and persons receiving mental health services covered by Oregon Health Plan or other public funding.
  • If I threaten to harm myself or others, CFD is required to intervene, which may include a report to the appropriate agency and/or authority.
  • In the event of threatened harm to any individual, my medical provider may warn the intended victim(s) by the most efficient means available.

Release of Information

  • CFD may communicate with other physical and behavioral health providers involved in my care. This communication may include the sharing of physical and mental health charts. The purpose of this communication is to provide me with quality, integrated healthcare and to ensure all of my health needs are being addressed by those involved in my care.
  • In cases of medical emergency, CFD may access emergency medical treatment on my behalf. Information may be released to the attending emergency workers but will be limited to only information that is necessary to resolve the situation. Any information shared will be documented in my record.
  • In cases of psychiatric hospitalization, information about mental health status prior to hospitalization and information judged to be helpful in service conclusion planning may be released. Any information shared will be documented in my record.
  • If a child abuse investigation is being conducted, CFD is required under Oregon law to permit the investigating agency to inspect and copy records of the child involved in the investigation without the consent of the child or the parent/guardian of the child.
  • If I have concerns about my information being released, I may submit a "Request for Restriction on Use/Disclosure of Clinical Information."

Legal Proceedings and Release of Records

  • If I am involved in or anticipate being involved in legal or court proceedings, I will notify my medical provider as soon as possible to help them understand how, if at all, their involvement in these proceedings might affect our work together.
  • If information regarding my services at CFD becomes an issue in a court proceeding, the Judge may decide to order my confidential information be disclosed.
  • My medical provider or other CFD staff will not volunteer confidential information within a court proceeding without my written permission.
  • Should a Judge order a disclosure of information regarding my therapy services, CFD staff will obey such an order.

Access to Records

  • I have the right to view and request copies of my record by written request, unless CFD determines access to my records would likely be harmful to my well-being, in which case a copy may be denied.
  • If I request copies of my record, I may be asked to pay for copy costs and staff time. I will not be denied access to my record because of inability to pay.


  • If I am prescribed medication, I agree to follow dosage requirements and attend follow-up appointments to ensure I will not run out of medication between appointments.
  • If I foresee running out of medication before my next appointment, I agree to call CFD directly, not the pharmacy, to request a prescription refill.
  • I must allow up to 5 days for my prescription to be filled once I have called CFD and made a prescription refill request. Refills will only be approved if current and due for refill.

Potential Side Effects

  • I will receive information on medication and potential side effects when the medication is initially prescribed.
  • I understand that should I experience unexplained, uncomfortable, or concerning side effects from medication prescribed, I will call CFD as soon as possible to address my concerns.

Urinalysis (UA)

  • I agree to provide urine samples when requested at time of the MAT evaluation and during treatment.
  • UA results will be used to determine my use of drugs and alcohol, to inform service planning and referral recommendations, as well as to monitor use of my prescribed medications.
  • UAs are monitored closely and observed as needed. The integrity of UAs is an essential element of medication management services to ensure medications are prescribed in a safe and effective manner.
  • I understand that the medical provider will take UA results into account and may decline to prescribe any medications based on my UA results.
  • I may ask for copies of my UA results.
  • If I am enrolled in CFD's Recovery Program, the medical provider will be in communication with the Recovery Program therapist regarding my services, including UA results.

Laboratory Testing

  • I may be asked to have lab testing done periodically to inform service planning and to ensure medications are prescribed in a safe and effective manner.
  • I may request copies of my lab results.

Medication History

  • CFD's electronic health record allows for the collection and review of my "medication history,” which is a list of prescription medicines that my CFD prescriber has recently prescribed me. An accurate medication history is important for proper treatment and for avoiding potentially dangerous interactions.
  • I give CFD permission to collect information about my prescriptions that have been filled at any pharmacy or covered by any health insurance plan. Also, by signing below, I give my pharmacy and my health plan permission to disclose such information. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health conditions, such as depression.
  • My medication history information will become part of my record.

Appointment Cancellation or Late Arrival:

  • If I need to cancel a medication management appointment, I will give as much notice as possible so the appointment time can be used by someone else.
  • If I do not give 24 hours' notice, services may be terminated after the third subsequent failure to give notice, or at the medical provider's discretion in the event of prolonged inconsistent attendance.
  • If I arrive more than 10 minutes late for an appointment, I may not be seen. This will constitute a no-show and the above policy will apply.

Third Party Payer:

  • If I am covered by a third-party payer, I authorize billing to my health plan and payment of benefits directly to CFD.
  • If I am covered by Oregon Health Plan, I am not required to pay for services provided to me.
  • I will inform CFD of any changes in my coverage as soon as possible. If I am covered by a payer for which coverage ends for any reason, I may be responsible for the full cost of treatment.
  • My information may be reviewed by my health plan, including the Oregon Health Authority or the local coordinated care organization, for funding authorization of services, quality improvement, utilization management and site review purposes.

Information Provided at Medication Management Evaluation:

  • I received a copy of the following information: Consent for Medication Management Services, Statement of Individual Rights, Notice of Privacy Practices, Authorization to Use and Disclose Protected Health Information, Crisis Services, Grievance Procedure, Tobacco Cessation Information, and Low-cost or Free Medical and Dental Services Information.

CFD provides services to all individuals who are eligible regardless of race, ethnicity, gender, gender identity, gender expression, sexual orientation, religion, creed, national origin, age (except when program eligibility is restricted to children, adults, or older adults), familial status, marital status, source of income, and disability.

My signature affirms that I have read and understand this form and have had the opportunity to ask questions.

This document is being signed by:

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.

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Signature Certificate
Document name: Consent for Psychiatric Services
lock iconUnique Document ID: f03b5989b96f0cd494e7e1dfa2a3bf153eeea7f1
Timestamp Audit
June 22, 2023 12:01 pm PDTConsent for Psychiatric Services Uploaded by Do Not Reply - IP
June 22, 2023 1:06 pm PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip: