Consent to Receive Psychotropic Medication
Consent to Receive Psychotropic Medication
I, ___________________________, hereby consent to receive psychotropic medication as prescribed by my Medical Practitioner/Psychiatrist. I have been informed of all of the side effects and adverse reactions to the medications. I understand that I may experience withdrawal symptoms at the time it is decided I should stop taking this medication.
My support team will monitor me very closely while I am on this medication. I will see the prescribing Medical Practitioner/Psychiatrist on an ongoing basis to monitor the effects of this medication.
The medication I consent to taking is ______________________ and the dosage is _______________________.
Possible side effects are: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(Complete portion above and sign either section A or B below for each medication)
A. If I am taking this medication to assist me in changing my behavior I have a behavioral support plan to address the specific behaviors this medication addresses. A Behavior Analyst has reviewed this plan and he/she will work with me in adjusting the plan as needed. My support team will make every effort to reduce the dosage within 30-days. Eventually I will no longer need this medication.
Consumer: ______________________________________________________ Date: _________________________
Conservator/Guardian: _____________________________________________ Date: _________________________
Administrator: ____________________________________________________ Date: _________________________
B. If I am taking this medication because I have a psychiatric diagnosis of ___________________________, I understand that these medications will help me to live a better life. I understand that if at any time I wish to withdraw (end) my consent (permission) I understand that I can call my Medical Practitioner/Psychiatrist, Dr. ____________________ at _______________________________ (phone #) for advice. If, after talking with my Doctor, I determine that I no longer want the medications, I will formally end my consent to take this medication.
Consumer: _______________________________________________________ Date: _________________________
Conservator/Guardian: _____________________________________________ Date: _________________________
Administrator: ____________________________________________________ Date: _________________________
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