PSYCHIATRIC CONTROLLED SUBSTANCE

MANAGEMENT AGREEMENT

This form acknowledges that if the use of a Controlled Substance medication for my psychiatric care is prescribed, it is 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.

Last Name *

Date of birth *

First Name *

Please Chex Boxes to Agree to Terms (ALL BOXES MUST BE CHECKED TO BE CONSIDERED VALID) *

I am aware that use of medication often has certain risks associated with it including habituation and dependence. I will review the risks and benefits information with my provider.

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 medication treatment plan.

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.

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.

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.

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 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.

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

I have read this agreement, and I fully understand the consequences of violating this agreement. I will

consult with my provider to answer my questions and I agree to the terms of this agreement.

Signature *

Clear

DATE *