I understand that I am seeking psychiatric–mental health services, which may include evaluation, diagnosis, treatment planning, psychotherapy, medication management, and/or other mental health interventions provided by a qualified mental health professional.

I understand that psychiatric–mental health treatment may involve:

• Clinical interviews and mental health assessments
• Psychotherapy or counseling
• Prescription and management of psychiatric medications (if applicable)
• Coordination of care with other healthcare providers
• Review of my medical, psychological, and social history

The specific treatment approach will be discussed with me and may change based on my individual needs.

I understand that potential benefits of treatment may include improvement in symptoms, functioning, and overall well-being.

I also understand that there may be risks, including but not limited to:

• Emotional discomfort when discussing sensitive topics
• Possible side effects of medications
• No guarantee of improvement

These risks and benefits have been explained to me, and I have had the opportunity to ask questions.

I understand that alternatives may include declining treatment, seeking services from another provider, or using non-psychiatric interventions. I understand that I may discuss these alternatives with my provider.

If medications are prescribed, I understand:

• The purpose of the medication
• Possible benefits and side effects
• Risks of not taking the medication as prescribed
• My responsibility to report side effects or concerns

I understand that information shared during treatment is confidential and protected by law. Exceptions to confidentiality include, but are not limited to:

• Risk of harm to myself or others
• Suspected abuse or neglect of a child, elderly person, or dependent adult
• Court orders or other legal requirements

These limits to confidentiality have been explained to me.

I understand that I have the right to:

• Ask questions about my treatment
• Participate actively in treatment decisions
• Withdraw consent or discontinue treatment at any time

I understand that I am responsible for providing accurate information and participating honestly in my care.

I acknowledge that:

• I have read and understood this consent form
• My questions have been answered to my satisfaction
• I voluntarily consent to receive psychiatric–mental health services