Consent to Treatment Form

1. Have received the client handbook

2. Have received a copy of, read and understand the Program Rules, Client's Rights and Client's Grievance Policy of the Graceland Psychiatry and agree to comply with the Program's rules Policies and Procedures

3. Understand I have the right to file a grievance towards program decisions regarding my care and/or any incidents of unfair, discriminatory, or unethical treatment

4. Understand that, it is my responsibility to take psychotropic medication as prescribed: as well as, remain free from illicit substances while receiving treatment at Graceland Psychiatry. I further understand that if I choose to use drugs while in this program, my treatment status will be reviewed, and I will be referred to an appropriate level of care *

5. Understand that, it is my responsibility to remain totally alcohol and drug free while receiving treatment at Graceland Psychiatry. I understand that I will be required to participate in urine screenings and breathalyzer monitoring and will be responsible for payment of associated fees in advance. I further understand that if I choose to use alcohol and/or drugs while in this program, my treatment status will be reviewed, and I will be referred to an appropriate level of care.

6. Understand upon request I can receive a list of community resources, including medical, vocational, mental health, legal, and social services.

7. Have been made aware of the fees for services

8. Consent to treatment at Graceland Psychiatry.

Client's Name

Signature of Client

Date

Signature of Clinician

Date