Fillable Printable Bhs Policy Form 108 1
Fillable Printable Bhs Policy Form 108 1
Bhs Policy Form 108 1
POLICY FORM 108.1
Informed Consent/Assent for Psychotropic Medication Treatment
LastRevision:06/10/2015
EffectiveDate:07/31/2015
Ihavediscussedthefollowinginformationwithmybehavioralhealthmedicalpractitioner(BHMP)foreachmedicationlistedbelow:
Thediagnosisandtargetsymptomsforthemedicationrecommended;
Thepossiblebenefits/intendedoutcomeoftreatment,andasapplicable,allavailableproceduresinvolvedinthe
proposedtreatment;
Thepossiblerisksandsideeffects,includingrisksofmedicationtopregnantwomenandwomenwhoarebreastfeeding;
Thepossiblealternatives;
Thepossibleresultsofnottakingtherecommendedmedication;
Thepossibilitythatmymedicationdosemayneedtobeadjustedovertime,inconsultationwithmybehavioralhealth
medicalpractitioner;
Myrighttoactivelyparticipateinmytreatmentbydiscussingmedicationconcernsorquestionswithmybehavioral
healthmedicalpractitioner;
Myrighttowithdrawvoluntaryconsentformedicationatanytime(unlesstheuseofmedicationsinmytreatmentis
requiredinaCourtOrder
orinaSpecialTreatmentPlan);
Forpersonsunder18yearsofage,theFDAstatusofthemedicationandthelevelofevidencesupportingthe
recommendedmedication;and,
Forpersonsunder18yearsofage,theyouthisencouragedtoassentoragreetothemedicationbutthe
youth’sguardian
orparenthasthefinalsayinconsentfortheuseofmedication.
Iunderstandthemedicationinformationthathasbeenprovidedtome.BysigningbelowIagreetotheuseofeachmedication.
Medication: HowwasMedicationInformationDiscussed?
In‐PersonOverTelephoneViaTelemedicinePreviouslyDiscussed*
Person’sInitials: BHMP’sInitials:
Date: Date:
Parent/Guardian’sInitials**:
Date:
TargetSymptomstobe
Addressed***:
Medication: HowwasMedicationInformationDiscussed?
In‐PersonOverTelephoneViaTelemedicinePreviouslyDiscussed*
Person’sInitials: BHMP’sInitials:
Date: Date:
Parent/Guardian’sInitials**:
Date:
TargetSymptomstobe
Addressed***:
Person’sPrintedName: Person’sSignature: Person’sInitials:
Parent/Guardian’sPrintedName: Parent/Guardian’sSignature: Parent/Guardian’sInitials:
BHMP’sPrintName: BHMP’sSignature: BHMP’sInitials:
Person’sName: Person’sID#:
*“PreviouslyDiscussed”indicatesthemedicationhadbeendiscussedinaprevioussetting(hospital,anotherclinic,etc.)orbyanother
behavioralhealthmedicalpractitionerandyouareverifyingthatthepersoncontinuestoconsenttotreatmentwiththismedication.
**Ensureinformedconsentformwithoriginalpatientsignatureislocatedin
patient'sfile.Ifconsentobtainedbytelephoneorthrough
tele‐medicine,individualmayinitialanddateatnextface‐to‐facevisit.
***TargetSymptomsrefertospecificsymptomsassociatedwithadiagnosis,suchastearfulness,hallucinations,insomnia.Listthetarget
symptomsratherthantheunderlyingdiagnosis.
****Additionalfieldsmust
beaddedtolistallpsychotropicagentsprescribedforthemember,iftheabovefieldsdonotallowenough
spacetoenterallcurrentagents.