Patient Information

Full Name Date of Birth Contact Number Email Address

Consent for Psychiatric Treatment

I acknowledge that I have been informed about the nature and purpose of psychiatric treatment, including possible risks, benefits, and alternatives. I understand that participation is voluntary and that I can withdraw my consent at any time.

I voluntarily consent to receive psychiatric treatment.

Confidentiality

I understand that my personal health information will be kept confidential except as required by law or with my written permission.

I acknowledge understanding of the confidentiality policy.

Questions & Comments

If you have questions or concerns, please list them below:

Patient Signature Date

Provider/Witness Signature Date

Psychiatric Treatment Consent Form

Patient Information

Consent for Psychiatric Treatment

Confidentiality

Questions & Comments