Consent For The Use Of Psychotrophic Medications

I, the undersigned, am requesting that psychotropic medications be used during the course of my treatment with Nikki Katibi, APNP, psychiatric nurse practitioner.

I fully understand that there may be some negative side effects that might occur due to the use of psychotropic medication(s). These side effects or symptoms, however rare, may include: worsening depression, suicidality, anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, severe restlessness, hypomania, and mania.

I am aware that it is the patient’s responsibility to immediately tell my treating psychiatric nurse practitioner if I experience any of the above symptoms or side effects. I also understand that it is my responsibility to follow all treatment recommendations including the discontinuation of the medication(s); the tapering off and discontinuation of the psychotropic medication(s); and/or the need to come in for a scheduled appointment.

By signing below, I acknowledge that I have read and understand this information. If client is a minor, please have the parent or legal guardian sign this form.

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InMindOut Emotional Wellness Center
Signature Certificate
Document name: Consent For The Use Of Psychotrophic Medications
Unique Document ID: bdb2a3f2f0bfffbe94348bb2ac2a9913298582b6
Timestamp Audit
August 2, 2018 5:53 pm CDTConsent For The Use Of Psychotrophic Medications Uploaded by imo imo - IP