(You may right click on the title of the form and save a copy of this document)
Consent for Mental Health Evaluation and/or Treatment
(Adult)

1. Consent to Evaluate/Treat:
 
I voluntarily consent that I will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or treatment by providers from Robin Casey MD, PLLC / Chatham North Psychiatry. I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:

a. The benefits of the proposed treatment
b. Alternative treatment modes and services
c. The manner in which treatment will be administered
d. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).
e. Probable consequences of not receiving treatment
 
The evaluation or treatment will be conducted by a psychiatrist (MD), psychotherapist, a psychologist, a psychiatric nurse practitioner, a licensed therapist or an individual supervised by any of the professionals listed. Treatment will be conducted within the boundaries of
North Carolina Law for Psychological, Psychiatric, Nursing, Social Work, or Professional Counseling.

2. Benefits to Evaluation/Treatment:
Evaluation and treatment may be administered with psychological interviews, psychological assessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to me, as well as the referring professional, to understand the nature and cause of any difficulties affecting my daily functioning, so that appropriate recommendations and treatments may be offered.

Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic/job performance, health status, quality of life, and awareness of strengths and limitations.

3. Charges:
Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. I will be responsible for any charges not covered by insurance, including co-payments and deductibles. Fees are available to me upon request.

4. Confidentiality, Harm, and Inquiry:
Information from my evaluation and/or treatment is contained in a confidential medical record at Robin Casey MD, PLLC / Chatham North Psychiatry, and I consent to disclosure for use by Robin Casey MD, PLLC / Chatham North Psychiatry providers for the purpose of continuity of my care. Per North Carolina mental health law, information provided will be kept confidential with the following exceptions:
1) if I am deemed to present a danger to myself or others;
2) if concerns about possible abuse or neglect arise; or
3) if a court order is issued to obtain records.

5. Right to Withdraw Consent:
I have the right to withdraw my consent for evaluation and/or treatment at any time by providing a written request to the treating clinician.
 
6. Termination of Care by Providers:
I understand that my provider also has the right to terminate care with me. Should my provider choose to terminate care with me, I will be notified in writing or verbally in person or by phone. I understand my provider and/or Robin Casey MD, PLLC / Chatham North Psychiatry will assist me, within reason, in finding a new provider. I understand that if I have have not been seen as a patient for a period of two or more years, you will automatically be considered terminated; in this situation you are welcome to reestablish care should you desire to restart care/services.

I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment. I also attest that I have the right to consent for treatment. I understand that I have the right to ask questions of my service provider about the above information at any time. My signature below indicates my agreement with the above.
 
 

---------------------------------------------
Patient Signature    
 
---------------------------------------------
Printed Patient Name
 
 ------------------------------
Date

Chapel Hill - Chatham North Office
117 Hidden Valley Drive
Chapel Hill, NC 27516

phone 919-998-6463

North Raleigh Mental Health and Wellness
920 Paverstone Dr, Suite D
Raleigh NC 27615
 
phone 919-896-6998