Patient Information

PATIENT INFORMATION

First name:_______________________________________

Last name:_______________________________________

Date of Birth:_____________________________________

Age:  ___________________

Email Address:___________________________________

Home Address:______________________________________

Mobile Number:_____________________________________

Address:_____________________________________________

Emergency Contact Name:______________________________

Emergency Contact Number:___________________________

I am currently experiencing:____________________________

How long have you been experiencing this?_______________________

How intense are your symptoms?________________________________

Have you seen a doctor regarding this?_______________________________

Are you currently on medications?_______________________________

Certifications (fit to work/medical certificate) – By booking an appointment, I agree as the patient that it is at the sole discretion of my clinician whether to issue a medical certificate, fit to work certificate, or not. ______

I understand that as a patient, I cannot dictate my clinician what to put or not to put in my certification/s._____

By signing and submitting this document I agree that I am NOT going through a medical emergency

Patient Consent Agreement 

I, the Patient, by submitting this form and making payment, hereby consent to the assessments, services, prescription of medications, and treatments that are performed by the staff at Prescription Psychiatrists and Psychologists. 

Furthermore, I understand that all services are provided by an individually-licensed clinician and/or a clinician under the supervision of a licensed clinician. I understand that my treatment may include psychological assessment, counseling, talk therapy, prescription of medications, prescription of controlled medications, and/or other health-related treatments. 

It is my responsibility to use my discretion when using any treatment, medication, or accepting any advice given. I give permission for my patient records to be stored and transferred digitally if needed. 

I agree NOT to record in any form my online consultation/session with my clinician. 

I release Prescription Psychiatrists of all liability relating to any events, actions, communication, or outcomes that arise from the services and I understand that all services are the sole responsibility of the licensed signing clinician and that the corporation Prescription Psychiatrists and Psychologists are not liable for the outcomes of any treatment. 

I understand that there are no refunds for not attending appointments or cancellations without 24-48 hours emailed notice. I understand that my sessions with my clinician are not to be used in court cases/legal purposes unless a written agreement between me and my clinician was made before my first session commences. 

Tardiness Policy 

As you can imagine, late arrivals can set back our schedules significantly. As a courtesy to our patients, if you arrive late, your session will be shortened to the remainder of your original scheduled appointment. 

Cancellation Policy 

You may cancel or reschedule your appointment without charge prior to 24 hours in advance or by the end of business hours (7:00 pm) the day before your appointment. If you cancel or reschedule with less than the aforementioned notice or via voicemail after closing the business day preceding your appointment, you will be charged 100% of the scheduled service price. 

Signature_______________
Date: _________________

Note: Please fill out all information, as this will be your clinician’s guide during your session.

Incomplete forms will be sent back for completion and may affect your schedule.  

NO SUICIDE CONTRACT

___________________________________________________

Last Name                   First Name                     Middle Initial

___________________________________________________

Age                           Marital Status                  Phone Number

___________________________________________________

Permanent Address

___________________________________________________

Emergency               Contact Phone               Number Address

AGREEMENT

I _______________________________being fully aware of my situation do hereby completely agree to the following:

(1) abstain from all self – harm including suicide and self–mutilation. 

(2) Contact my counselor or any mental health professional before I engage in any form of self – harm 

(3) Obtain help and assistance whenever I feel the compulsion, strong desire, or need to harm myself in any way including suicide, self–mutilation, and by accident. 

The company shall not be responsible and shall not assume liability for any such injury to and death of the client. 

Client Signature Date Signed 

Witness Signature Date Signed

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