Electroconvulsive Therapy (ECT) Informed Consent

# Electroconvulsive Therapy (ECT) Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Provider / Practice:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Treating Clinician(s) **Psychiatrist:** ___________ **Anesthesiologist:** ___________ **Facility / ECT Suite:** ___________ --- ## 2. Diagnosis and Indication **Psychiatric Diagnosis:** ___________ **Reason ECT Is Recommended:** ___________ ECT is recommended because the above condition poses a significant risk of harm and has not responded adequately to (or cannot safely be managed with) alternative treatments, including the medications and therapies listed in Section 10. The clinical urgency and/or treatment resistance makes ECT an appropriate intervention at this time. --- ## 3. Description of ECT Electroconvulsive therapy is a medical procedure performed under general anesthesia in which brief electrical stimulation is applied to the scalp to induce a controlled generalized tonic-clonic seizure lasting approximately 20–60 seconds. The therapeutic mechanism is not fully understood but involves neurochemical changes — including increases in neurotransmitter release, neuroplasticity, and neuroendocrine modulation — that produce rapid antidepressant, anti-manic, and anti-catatonic effects. ### What Happens During a Treatment Session