Name * First Name Last Name Email * Risk and Benefits of Treatment * Mental health services are generally effective at treating many mental health conditions. The patient’s provider will monitor their progress and outcomes to make sure that they benefit from the treatments. Benefitting from treatment requires the patient’s attendance at appointments and their dedication to following their provider’s advice and recommendations. The patient’s treatment is a process, and it may involve both benefits and challenges. You/the patient are encouraged to discuss these challenges with the patient’s provider. The patient’s provider cannot guarantee any specific results of their treatment. Privacy * Patient records are our personal property and shall be treated as confidential. Please note that all patient charts are kept for seven years. Once seven years has elapsed since the patient’s last appointment, the records are destroyed. At times, the patient’s provider may need to consult with another professional in their areas of expertise to provide the best possible treatment to the patient. Information about the patient or their treatment may be shared in this context without using the patient’s name or other identifiable information. Additional information regarding privacy practices is contained in the Notice of Privacy Practices which was provided to you. First Name Last Name EMERGENCIES * In case of a true emergency/crisis situation, please call 911 (988 for mental health emergencies) and/or go to the nearest emergency department, Great Lakes Psychiatrists 313-759-7102 Hours: M–F 9 pm–5 pm Sign Below CONSENT FOR TREATMENT WITH PSYCHOTROPIC MEDICATIONS Prescriber’s Name Dr. Oksana Lidke My prescriber is recommending that I be treated with the following medication(s): Before I signed this form, I talked to my doctor. I understand: The kind of condition I have. The reason why my medication is given to patients with my condition. The way the medication may benefit me. The most important kinds of problems (risks and discomforts) that the medication can reasonably be expected to cause patients with my condition. Other kinds of choices (alternatives for care) if I do not take the medication(s). My prescriber has explained to me that there may be other risks if I take the medication. They are believed to be small, are not expected, or are unknown. I understand that because it can be dangerous to stop taking a medication too quickly, I may have to continue taking a medication for a time even after I decide to have it stopped. No one has given me a promise or guarantee to what will happen if I take the medication. All of my questions about the medication have been answered. I know that I can ask my doctor questions which I think of later, and my doctor will answer them. After thinking about all these things, I have decided that I want to take the medication listed at the top of this form. I give my consent to receive the medication at the top of this form. I also give my consent to my prescriber to change the amount, times, combination, and ways the medication is given as they think best. I know that if I agree to receive the medication, and later change my mind, I must tell my doctor. I understand that I may withdraw this consent at any time (verbally or written). I know that I should tell my doctor immediately if there are any changes in my condition after I begin taking the medication. First Name Last Name Client Text Message Consent Form * I hereby give my consent for “Great Lakes Psychiatrists” to send text message reminders to my mobile phone (as per the number above). These messages will be a reminder of my previously booked appointment date and time, or a notification that I need to reschedule an appointment. Should I not be able to keep an appointment, I will call the office to cancel. All patients have the right to change their minds and have this service stopped. If you no longer wish to receive these text reminders, please notify reception. We cannot accept incoming text messages. If you change your mobile number please inform us so that we can update our records. First Name Last Name Emergencies * In case of a true emergency/crisis situation, please call 911 (988 for mental health emergencies) and/or go to the nearest emergency department, Great Lakes Psychiatrists 313-759-7102 Hours: M–F 9 pm–5 pm First Name Last Name Thank you! Name * First Name Last Name Email * Risk and Benefits of Treatment * Mental health services are generally effective at treating many mental health conditions. The patient’s provider will monitor their progress and outcomes to make sure that they benefit from the treatments. Benefitting from treatment requires the patient’s attendance at appointments and their dedication to following their provider’s advice and recommendations. The patient’s treatment is a process, and it may involve both benefits and challenges. You/the patient are encouraged to discuss these challenges with the patient’s provider. The patient’s provider cannot guarantee any specific results of their treatment. Privacy * Patient records are our personal property and shall be treated as confidential. Please note that all patient charts are kept for seven years. Once seven years has elapsed since the patient’s last appointment, the records are destroyed. At times, the patient’s provider may need to consult with another professional in their areas of expertise to provide the best possible treatment to the patient. Information about the patient or their treatment may be shared in this context without using the patient’s name or other identifiable information. Additional information regarding privacy practices is contained in the Notice of Privacy Practices which was provided to you. First Name Last Name EMERGENCIES * In case of a true emergency/crisis situation, please call 911 (988 for mental health emergencies) and/or go to the nearest emergency department, Great Lakes Psychiatrists 313-759-7102 Hours: M–F 9 pm–5 pm Sign Below CONSENT FOR TREATMENT WITH PSYCHOTROPIC MEDICATIONS Prescriber’s Name Dr. Oksana Lidke My prescriber is recommending that I be treated with the following medication(s): Before I signed this form, I talked to my doctor. I understand: The kind of condition I have. The reason why my medication is given to patients with my condition. The way the medication may benefit me. The most important kinds of problems (risks and discomforts) that the medication can reasonably be expected to cause patients with my condition. Other kinds of choices (alternatives for care) if I do not take the medication(s). My prescriber has explained to me that there may be other risks if I take the medication. They are believed to be small, are not expected, or are unknown. I understand that because it can be dangerous to stop taking a medication too quickly, I may have to continue taking a medication for a time even after I decide to have it stopped. No one has given me a promise or guarantee to what will happen if I take the medication. All of my questions about the medication have been answered. I know that I can ask my doctor questions which I think of later, and my doctor will answer them. After thinking about all these things, I have decided that I want to take the medication listed at the top of this form. I give my consent to receive the medication at the top of this form. I also give my consent to my prescriber to change the amount, times, combination, and ways the medication is given as they think best. I know that if I agree to receive the medication, and later change my mind, I must tell my doctor. I understand that I may withdraw this consent at any time (verbally or written). I know that I should tell my doctor immediately if there are any changes in my condition after I begin taking the medication. First Name Last Name Client Text Message Consent Form * I hereby give my consent for “Great Lakes Psychiatrists” to send text message reminders to my mobile phone (as per the number above). These messages will be a reminder of my previously booked appointment date and time, or a notification that I need to reschedule an appointment. Should I not be able to keep an appointment, I will call the office to cancel. All patients have the right to change their minds and have this service stopped. If you no longer wish to receive these text reminders, please notify reception. We cannot accept incoming text messages. If you change your mobile number please inform us so that we can update our records. First Name Last Name Emergencies * In case of a true emergency/crisis situation, please call 911 (988 for mental health emergencies) and/or go to the nearest emergency department, Great Lakes Psychiatrists 313-759-7102 Hours: M–F 9 pm–5 pm First Name Last Name Thank you!
