MEDICATION CONSENT FORM – UNDER 18

I understand that this medication is being prescribed for the treatment of symptoms of a mental or emotional disorder. It is the clinician’s opinion that this medication(s) may be helpful for the condition(s) for which I am seeking treatment. However, I understand that there is no guarantee that it will be helpful. Alternative treatment options have been discussed with me. 

I understand that my response to this medication will be monitored to assess its effectiveness and it will be prescribed in what is thought to be the most effective dose. 

Please be advised that the medication(s) prescribed might be for an off label indication (not FDA approved).

For Antidepressant medications: Before consenting to the use of an antidepressant, please be advised that the Food and Drug Administration (FDA) has voiced concerns about antidepressant treatment. There have been reports, and participating European literature, that some antidepressants may increase violent or suicidal behavior. This warning does not reflect the opinions or expertise of the Medical Director of the Behavioral Medical Center, but it is important to understand the full debate before offering consent. If you exhibit any of these behaviors, please contact us or obtain care emergently. * For further information, the FDA advisory can be found at: http://www.fda.gove/cder/drug/antidepressant/default.htm.

I understand the medication(s) prescribed may produce side effects and I understand and have received oral and written instructions, as well as a list of the most common and serious side effects of this medication(s). I understand the importance of reporting side effects or unusual reactions to my clinician. If necessary, I agree to follow any recommendations given to me regarding the monitoring of my clinical condition, including blood studies, cardiograms, height and weight measurements, and any other physical monitoring in pregnancy.

**For adolescents of childbearing age:
Parent/guardian  agrees to  notifying prescriber of any changes related to pregnancy/breast feeding immediately as there is no safety data for medications in pregnancy and/or breastfeeding.

Parent or Guardian Signature