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2025 Psychotropic Contract
Psychotropic Medications: Patient Agreement
Name
First
Last
Date of Birth
Month
Day
Year
Provider
--Please Select--
Lisa Bates
Laura Davis
Miriam Dineen
Cliff Harper
Joe Harris
Larisa King
Morgan Kingrey
Brian McCarthy
Adam McDonough
April Nandigam
Grace Nicklas-Morris
Madison Stonewall
Kadie York
This form will go directly to the person you select.
Today's Date
Month
Day
Year
Examples of Controlled Substances:
Benzodiazepines:
Alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), clobazam (Onfi), clorazepate (Tranxene), diazepam (Valium), estazolam (ProSom), flurazepam (Dalmane), lorazepam (Ativan), midazolam (Versed), oxazepam (Serax), quazepam (Doral), temazepam (Restoril).
Stimulants:
Methylphenidate (Ritalin, Concerta, Metadate, Methylin, Daytrana), dexmethylphenidate (Focalin), amphetamine-salts (Adderall, Evekeo), dextroamphetamine (Dexedrine, Vyvanse, Zenzedi).
Sleep Medicines:
Eszopiclone (Lunesta), zaleplon (Sonata), zolpidem (Ambien, Edluar, Intermezzo), suvorexant (Belsomra), lumborexant.
Opioids*:
Buprenorphine, codeine, hydrocodone, hydromorphone, fentanyl, meperidine, morphine, tramadol, oxycodone, oxycontin.
Other:
Modafinil (Provigil, Nuvigil), pregabalin (Lyrica), dronabinol (Marinol)*, gamma hydroxybutyric acid (Xyrem)*, barbiturates*.
*Not prescribed at the Mood Treatment Center
I understand and voluntarily agree that (initial each statement after reviewing):
(Required)
I will keep the medicine safe, secure, and out of the reach of children.
I will take my medication as instructed and not change the way I take it on my own.
I will not sell this medicine or share it with others.
I understand that I have been given prescription(s) for enough medicationuntil my next office visit (including necessary refills). If I need additional medicationdue to a missed appointment, I will need to call for an urgent appointment.
I will make sure I have an appointment for refills. If I am having trouble makingan appointment, I will tell a member of the treatment team immediately.
I will keep (and be on time for) all my scheduled appointments with the provider and other members of the treatment team.
I will always treat the staff at the office respectfully.
I will sign a release form to allow the provider to speak to other providers that I see.
I will tell the provider all other medicines that I take and let them know right away if I have a prescription for a new medicine.
I will not accept or obtain prescriptions for benzodiazepines (Klonopin, Xanax, Ativan, Valium, etc.) or stimulants (Ritalin, Adderall, etc.) fromother providers. If I am prescribed pain medication that contains opioids, I will promptly notify my provider of the prescription.
I will promptly notify my provider if I take medications that are not prescribed for me including amphetamines, cocaine, opioids, fentanyl, benzodiazepines, and cannabis products.
If I am capable of becoming pregnant - I recognize there may be serious potential risks of taking psychotropic medications on a fetus and growingbaby. I will discuss my plans to get pregnant with my provider and notify my provider promptly if I become pregnant.
I understand that I may lose my privilege to be treated in this office if I break any part of this agreement.
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