I understand that I am eligible to receive a range of services from my provider. The type and extent of these services will be determined after an initial assessment and thorough discussion. The purpose of the assessment is to identify the best course of treatment for me. Generally, treatment is comprehensive, progressive, and requires ongoing assessment and evaluation. My signature below authorizes my mental health provider to treat me. This treatment may include medications, lab tests, diagnostic tests, and educational support. I understand that my provider is available to explain the treatment options, and I have the right to refuse treatment. I may also be asked to sign additional forms to indicate my consent for specific treatments.

 I CONSENT to the services rendered by Thrive Mental Health Services, which may include evaluations, consultations, diagnostic testing, clinical therapies, and medication management, if appropriate. The providers at Thrive Mental Health Services have informed me of the nature of the recommended treatment and have explained the benefits, risks, and alternative approaches to care.

I acknowledge that the success of treatment can vary among patients, depending on the severity of their issues, their capacity for introspection, and their motivation to apply what they learn outside of sessions. While Thrive Mental Health Services providers may determine that certain treatments are likely to help me, there are no guarantees that my condition will improve.

Providers at Thrive Mental Health Services may prescribe medications. Not all patients are suitable candidates for medication therapy or will experience success with it. Sometimes, it may take several different medications before a patient sees improvement in their symptoms. These medications can have side effects that I agree to discuss regularly with my provider and my pharmacist.

I understand that medication treatment can affect my brain, body, emotions, actions, sleep, memory, judgment, coordination, stamina, and sexuality. Many medications require strict adherence to dosage and frequency, as well as close follow-ups and, in some cases, regular blood tests. This consent indicates my understanding of these responsibilities and risks.

I recognize that while Thrive Mental Health Services providers have explained the treatment to me, unexpected problems may arise. It is my responsibility to inform my provider about any unexpected changes in my condition or any issues related to my treatment. In case of an emergency, I will call 911 or go to an emergency room.

I have had the opportunity to ask questions about my treatment and have been given the chance to decline treatment. My consent for treatment has been provided voluntarily.

By signing below, I certify that I have read and understand the terms stated in this Treatment Consent Form, and I consent to treatment.

I must authorize my provider to release written information about my treatment; however, I acknowledge that confidentiality may be broken under certain circumstances involving danger to myself or others. I understand that once information is released to insurance companies or any third party, my provider cannot guarantee that it will remain confidential. When I consent to services, all information is kept confidential except in the following circumstances:

– When there is a risk of imminent danger to myself or another person, my provider is ethically bound to take necessary steps to prevent such danger.

– When there is suspicion of sexual or physical abuse of a child or elder, or when they are at risk of such abuse, my provider is legally required to take steps to protect the individual and inform the proper authorities.

– When there is a valid court order issued for medical records, my provider is legally obligated to comply with such requests. While this summary provides an overview of confidentiality and its limitations, I must read the Notice of Privacy Practices, which was provided for more detailed explanations, and I can discuss any questions or concerns with my provider. By my signature below, I voluntarily request and consent to behavioral health assessment, care, treatment, or services, and I authorize my provider to provide necessary and advisable care.

I understand that behavioral health treatment is not an exact science and acknowledge that no guarantees or promises have been made regarding the results I may receive. By signing this Informed Consent to Treatment Form, I acknowledge that I have read and understood the terms and information. I have also been given ample opportunity to ask questions and seek clarification on anything unclear.