Consent For The Use Of Psychiatric/Psychological Treatment


I, understand, authorize and consent to the performance of psychiatric or psychological treatment and/or testing considered necessary or advisable by Nikki Katibi, APNP.

I understand I have the right to refuse treatment. I understand that my refusal to follow treatment recommendations may result in my termination as a patient with Nikki Katibi, APNP. I understand that it is my responsibility to inform my provider if I am unwilling to follow treatment recommendations or have any questions regarding treatment or treatment recommendations.

If client is a minor, please have the parent or legal guardian sign this form.

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InMindOut Emotional Wellness Center https://inmindout.com
Signature Certificate
Document name: Consent For The Use Of Psychiatric/Psychological Treatment
Unique Document ID: aa867aed8b7d4ab111319c4bc79bec2306837f4c
Timestamp Audit
August 2, 2018 5:46 pm CSTConsent For The Use Of Psychiatric/Psychological Treatment Uploaded by imo imo - imo@inmindout.com IP 23.122.45.227