Psychiatric Evaluation & Medication Management Consent

# Psychiatric Evaluation & Medication Management Consent > **Important — not medical advice.** For use by a licensed provider; verify state scope-of-practice and informed-consent rules. **Date:** ___________ **Practice Name:** ___________ **Psychiatrist / Prescriber:** ___________ **Credential / License Number:** ___________ **Patient Name:** ___________ ("Patient") **Date of Birth:** ___________ --- ## 1. Purpose of the Evaluation (a) The Patient consents to a comprehensive psychiatric evaluation, which may include a structured clinical interview, review of prior psychiatric, medical, and medication records, standardized rating scales, coordination with other treating providers, and, if clinically indicated, referral for psychological testing or laboratory studies. (b) **Referral Source:** ___________ (c) **Primary Reason for Evaluation:** ___________ (d) **Additional Concerns:** ___________ --- ## 2. Scope of Psychiatric Services (a) This practice provides psychiatric evaluation and medication management. Psychotherapy, when indicated, is typically provided by a separately contracted or affiliated therapist. (b) **Services to be Provided:** Psychiatric Diagnostic Evaluation: ___________ Medication Management (prescribing, monitoring, adjustment): ___________