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Tranquility BHC Medication Management Consent Form


I, the undersigned,

understand that I am about to be prescribed one or more drugs by my provider. I understand that although my clinician says that I am sick or that I have a treatable illness or disease, he or she is just using a figure of speech and cannot establish, with any test or procedure known to medical science that I in fact "have" the "illness" implied by the diagnostic label. Indeed, I am aware that although medical opinion may now hold that a "chemical imbalance," a "brain abnormality," or some physical problem "underlies" or "produces" my distress or suffering, no objective information (through lab tests, scans, etc.) concerning the state of my body has been obtained in order to arrive at a DSM-V diagnosis. If, by chance, such information has been obtained for that purpose, I understand that this information plays no role whatsoever in fulfilling any criteria for any DSM-V diagnosis or diagnoses that I have been given by my clinician except perhaps for diagnoses related to drug-induced disorders such as tardive dyskinesia.


My authorized prescribing clinician met with me and we talked about Condition(s), for which treatment is being recommended; Dosage of medication, and how I will take it (by mouth or injection); Duration of treatment (no more than one year at a time); e) desirable outcomes of the proposed treatment (prognosis with treatment); Risks, benefits and side effects of the treatment; Dangers of abruptly discontinuing medications and how to safely discontinue medications; Feasible alternative treatments, including benefits, risks, and probable effectiveness of each medication; Possible outcomes if no treatment is received.



Risks, benefits, alternative to treatment and side effects of medication discussed with patient who verbalized understanding and agreement with this treatment plan Abstain from all illicit drugs, alcohol or mind-altering substances. Tell a friend; call the office; call 911 or go to nearest ER if you develop thoughts of harming self or others or develop symptoms of psychosis; call crisis line at 713-HOTLINE / (713) 468-5463 Safety plan discussed with patient: Risks & benefits, side effects, any common issues about the medications has been explained to the patient including but not limited to the following: Patient/Parent/Guardian made aware of worsening suicidal ideation, weight gain, metabolic syndrome, life-threatening rash, tremors, EPS, tardive dyskinesia, chest pain, tachycardia, appetite changes, cardiac arrhythmia, seizures, thyroid problems renal dysfunction. I have been informed about ?off label? use of the prescribed medications and explained the meaning of ?off label? use to the patient and he/she has been warned that the medications can cause drowsiness and impair his or her ability to operate a motor vehicle Antipsychotics (MOOD STABILIZER) ? ACUTE DYSTONIA (will always be reviewed with patient during the visit) Explaining that this is an irreversible condition that may occur and there is treatment to manage this neurological condition. Also discussed that theses medications can cause headache, dizziness, agitation, akathisia/restlessness, weight gain, nausea, constipation, elevated blood sugar, elevated lipids, diabetes, hypertension, metabolic syndrome, low white blood cell count, elevated liver enzymes, extrapyramidal symptoms, elevated prolactin levels, sensitivity to heat. Importance of monitoring for side effects with lab testing before initiation of pharmacotherapy and at regular intervals. FDA Black Box Warning concerning suicidality in children and adolescents reviewed/a I verbally consent to taking prescribed medications and I am aware of all the risks and benefits associated with taking the medications. In the event I develop TARDIVE DYSKINESIA from being prescribed an antipsychotic, I will not hold my clinician liable as he or she has explained that is may happen as a result of taking this class of medications for an extended period of time.


I have been counseled on the importance of medication adherence and the outcomes of not adhering to the medication regimen. I have been counseled extensively about medication adherence and stopping the medications may lead to negative outcomes and symptom exacerbation. I have been counseled on abstaining from illicit drug use and abstaining from alcohol intake. If a female, she has been told about the use of contraception as they should not get pregnant while taking these medications without informing the prescribing provider.


She has been warned about the risks of taking psychotropic medications during pregnancy as it may cause teratogenic and/or developmental issues to the fetus in utero.


The information I was given for each treatment is summarized below. I have also received a voided copy of all medications sent to the pharmacy electronically and information about the proposed treatment. I understand the risk and benefits of the medications and agree with my treatment plan.

By inputting your full name in this section, you are agreeing to the above mentioned terms/conditions, and that this will serve as your digital signature.


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