Consent for Treatment - Convoy Office Forms

Consent for Treatment

Nicodemus M. Watts, MD, DFAACAP
Your initial session for evaluation will last up to 180 minutes. During this time Nicodemus M. Watts, MD, DFAACAP will review the difficulties you are experiencing and will begin to develop a comprehensive treatment plan with you.

The plan may include referrals to another therapist or physician better suited to your needs as well as to different modes of treatment such as individual, group or community resources.

Any further recommended therapy sessions will last approximately 50 minutes. Medication follow up visits will last up to 30 minutes and when necessary, up to 60 minutes.

Treatment will be based on your clinical needs according to preferred practice guidelines that have been demonstrated to be most effective in overcoming the difficulties you are experiencing.

I have read and understand the above and consent to treatment provided by Nicodemus M. Watts, MD, DFAACAP.
Signature of Patient *

Clear
Printed Name *
Date *

Month Day Year
Date
Witness Signature

To be completed by your physician Clear
Printed Name
Date

Month Day Year
Date
Nicodemus M. Watts, MD, DFAACAP Diplomate, American Board of Psychiatry & Neurology Distinguished Fellow, American Academy of Child & Adolescent Psychiatry Child, Adolescent & Adult Psychiatry
3760 Convoy Street, Suite 113 San Diego, CA 92111-3743 Office: (858) 598-5207 Fax: (858) 598-5089
Should be Empty: