Consent for Services: Psychiatric Services Addendum

Center for Family Development

1258 High Street, Eugene, OR 97401 541-342-8437 / Fax 541-242-2999

Name:     Date of Birth:

Consent for Services: Psychiatric Services Addendum

Entry & Assessment

  • As part of my request for psychiatric services at Center for Family Development (CFD), I authorize clinical staff to complete a psychiatric evaluation and provide medication management services, if needed.
  • I may ask questions at any time.
  • My request for services from CFD is voluntary and I may discontinue services at any time.

Participation in Therapy

  • My psychiatric services provider is a Medical Doctor or Psychiatric Nurse Practitioner who will work in coordination with my behavioral health therapist to provide me with comprehensive and appropriate services.
  • I must be actively involved in services with my therapist in order to be provided psychiatric services.
  • If I discontinue or do not actively participate in services with my therapist, psychiatric services will also be discontinued and psychiatric care will be transferred to another provider.

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, psychiatric services may be terminated after the third subsequent failure to give notice, or at my psychiatric services 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.


  • 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 my pharmacist directly, not CFD, to request a prescription refill.
  • I must allow up to 5 days for my prescription to be filled once I have called my pharmacy and made a prescription refill request.

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 psychiatric 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 psychiatry services to ensure medications are prescribed in a safe and effective manner.
  • I understand that my psychiatric provider will take UA results into account and may decline to prescribe any psychotropic 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 psychiatric 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 CFD or other doctors have recently prescribed me. An accurate medication history is very 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.

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.

Leave this empty:

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Document name: Consent for Services: Psychiatric Services Addendum
lock iconUnique Document ID: 524c14b49bba806acfa583c95a1f99f3cec59643
Timestamp Audit
April 15, 2020 4:02 pm PDTConsent for Services: Psychiatric Services Addendum Uploaded by Jason Dooley - IP
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March 18, 2021 1:50 pm PDT Document owner has handed over this document to 2021-03-18 13:50:57 -
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