Geriatric Behavioral Health Consent Form

Patient Name

Date of Birth

Phone Number

Date

Purpose of Treatment

Consent to Behavioral Health Evaluation and Treatment

I consent to receive geriatric behavioral health evaluation and treatment.

Confidentiality

Risks and Benefits

Alternative Treatments

Right to Withdraw

I understand that I may withdraw my consent at any time.

Patient or Legal Representative Signature

Signature

Date

Printed Name

Relationship to Patient (if applicable)