Psychiatric Controlled Substance Management Agreement

This form acknowledges that the use of a Controlled Substance medication for my psychiatric care was a decision made between my provider and myself because of my specific condition. By signing this form, I acknowledge, understand and agree to the following conditions to make my treatment as safe and successful as possible. Please initial:

Name: *

First and Last Name

Date of Birth: *

1.) I am aware that use of this medication has certain risks associated with it including habituation and dependence. I have reviewed the risks and benefits information with my provider. *

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2.) I agree to help myself by actively participating in psychotherapy to reach my treatment plan goals, maintaining as healthy a lifestyle as possible, refraining from illicit drug use, and remaining compliant with treatment plan. *

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3.) I agree to notify my provider of any changes, emergency room visits, and/or acute psychiatric service visits, lost or stolen medication, or any other circumstances affecting my health and well being. *

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4.) I agree to receive the prescribed controlled substance only from my psychiatric provider. I will not seek this medication from any other provider, friend, relative, or non-prescriber while I am under psychiatric care at Plymouth Psych Group, except during the case of hospital admission medication changes. I am aware that my provider has access to, and will be reviewing my patterns of filling prescriptions through the Minnesota Prescription Monitoring Program. *

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5.) I understand that I may be subject to alcohol and drug screening, and a positive screen may prevent refills and/or result in termination of psychiatric services at Plymouth Psych Group. *

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6.) I understand the following refill protocol will apply, unless I have made previous arrangements with my provider: a.) Medication will not be refilled early, even if they have been lost, stolen, or destroyed AND b.) I understand that I have to meet with a psychiatric provider to get a refill. There are no “call-in’s” allowed for Controlled Substances. *

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7.) I agree to keep all appointments with psychotherapy and psychiatric medication providers *

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8.) I understand that if I fail to comply with the guidelines in this agreement, my provider or Plymouth Group may terminate psychiatric services. *

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I have read this agreement, and I fully understand the consequences of violating this agreement. My provider has answered my questions and I agree to the terms of this agreement.

Client Signature: *

Clear

Date: *

Date

PSYCHIATRIC CONTROLLED SUBSTANCE MANAGEMENT AGREEMENT