Prescriptions is/are controlled substances that are prescribed as part of your mental health treatment. This agreement allows us to work together in good faith, as partners, in creating a safe and appropriate treatment plan for the management of your mental health condition(s). The goals of the medication are: To improve my ability to work, to improve my ability to participate in therapy, to improve my ability to participate in school, to improve my ability to function at home, and to develop a short-term plan to reduce anxiety while my long-term treatment has time to reach full strength.

I agree:

• I will only use one pharmacy to get my medications.
• I will not obtain any addictive or controlled medications without telling a member of the treatment team before I fill the prescription.
• Patients need to be seen before refills are given. Early medication refills will not be authorized, and medication extensions will not be granted when I am due for an office follow-up. I understand the only exception is for emergencies overnight or on weekends.
• If I see another doctor/provider who gives me a controlled medication (I must bring the medication into my next appointment in the original bottle, even if the medication is gone.
• I will tell the provider all the medications that I am taking and let them know right away if I have a prescription for a new medication.
• I am taking medication with potential harmful side effects. I have reviewed these side effects with my provider.
• I will obtain controlled medication from one provider and will fill the medication at one pharmacy. I understand that I may not obtain controlled medications from multiple sources.
• I will take the medication exactly as prescribed and will not change the medication dosage or frequency on my own.
• I will keep my medication in a secure location. Lost, stolen, or misplaced prescriptions or medications will not be replaced.
• Medication can be dangerous for children, and I will not keep it in any place where a child or others may have access to it.
• I will not sell or share my medications. I understand that doing so is a felony and that the medication that is safe and effective for me can cause dangerous side effects to another person.
• I will make sure I have an appointment for refills. If I have trouble scheduling an appointment, I will discuss it with my provider via the secure messaging portal.
• I will always treat all staff at the office respectfully. I understand that if I am disrespectful to staff or disrupt the care of other patients, my treatment may be stopped.
• I will not abuse alcohol or street drugs, including marijuana or opioid pain medications, while taking this medication.
• I will provide blood or urine drug screens and other diagnostic testing if clinically indicated in the judgment of the provider.
• I will bring my bottle of pills in for pill counts to each appointment, and when asked.
• I will attend regular follow-up appointments as directed by the provider.
• My Provider may decide to stop my controlled medication due to other mental health or medical issues at any time deemed necessary.
• Controlled medication may only partially treat my condition. I will participate in other referrals or treatments which my provider recommends for the management of my mental health condition(s).
• I agree that while taking this medication, my provider may discuss my medication use with other doctors or family members for corroborating information about my care and use of medication. I will be asked to sign a release at that time.

Termination of Agreement:
If I am unable to adhere to the above treatment agreement, or if my clinical provider decides that this medicine is hurting me more than helping me, this medicine may be tapered/stopped by my clinical provider in a safe way.

I have discussed this agreement with my provider and understand and agree to the above rules.

Provider Responsibilities:
As your provider, I agree to conduct regular checks to assess how well the medication is working. I agree to provide mental health care for you even if you are no longer getting controlled medications from me. I affirm that I have full rights and power to sign and be bound by this agreement. You further affirm that you have been given the opportunity to ask any questions you may have and that you have read, understand, and accept all its terms.

TREATMENT CONSENT:
By signing below, you certify that you have read and understand the terms stated in the Treatment Consent Form. You indicate that you understand the scope of my services, session structure, fees, cancellation/no-show policies, payment policy, insurance reimbursement, confidentiality, the nature of my practice, and my contact information, and that you agree to abide by the terms stated above during our therapeutic relationship.