I/my child am/is a patient of the CCS physician/nurse practitioner who recommends that I/my child receive
medication(s) for the treatment of my/my child’s psychiatric and/or behavioral problems, in addition to other
mental health services.
The physician/nurse practitioner has informed of the nature of the treatment and has explained to me the rationale,
benefits, contraindications, and possible risks and side effects, including risks associated with pregnancy. The
physician/nurse practitioner has also informed me of the need for any laboratory monitoring.
If the prescribed medication is a neuroleptic, I have been informed of the risk of Tardive Dyskinesia, which
may cause involuntary tic-like movements in the face, tongue, neck, arms, and/or legs which may persist
even after the medication treatment is terminated.
If the prescribed medication is Trazadone, I have been informed of the risk of Priapism.
If the prescribed medication is a stimulant, I have been informed of tics, which are sudden, rapid,
recurrent, nonrhythmic, stereotyped motor movements, or vocalizations. These tics may persist even after
the medication is terminated.
If the prescribed medication is an atypical neuroleptic, like Zyprexa, Clozaril, Risperdal, Seroquel, Geodon,
or Abilify, I have been informed of the possibility of developing or exacerbating hyperglycemia and/or
I have been informed of potential implications between the prescribed meds and diet/exercise, as well as special
dietary needs and restrictions associated with the prescribed meds. I have been made aware of early signs of relapse
or nonadherence to prescribed meds, e.g., worsening mood or behaviors. I have been informed of potential drug
reactions when combining prescribed meds to non-prescribed meds, drugs, alcohol, tobacco, caffeine, illegal drugs,
and/or alternative medicines. I have been given instructions on how to self-administer the medication, if applicable.
I have been informed that some/all of these medications may not be approved by the FDA for children/adolescents/
adults. Some/all of the medications may not be approved by the FDA for the condition(s) I/my child have/has. I
understand that, although the physician/nurse practitioner has explained to me the most common side effects of this
treatment, there may be other side effects, and that I should promptly inform the physician/nurse practitioner or a
member of the clinical staff at Churchill Counseling if there are any unexpected changes in my/my child’s condition.
I understand that I/my child am/is not compelled to take the medication(s) and that I may decide to stop taking the
medication(s) at any time. If I do choose to stop taking the medication(s), I am obligated to inform the physician,
nurse practitioner, or a member of the clinical staff at Churchill Counseling. I understand that there is no
guarantee that this medication(s) will achieve the expected results. I have also received information about the
importance of taking the medication as prescribed, potential obstacles to adherence, and alternatives to the
As part of my wellness management and recovery planning, I will follow my treatment plan and be kept informed of
the progress of my treatment. I understand that if I consent to this medication, the dosage range may not be
increased or changed without my further verbal agreement. I have been informed that many drug companies offer
financial assistance, and I may obtain this information upon request.