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Medication & Psychotherapy Consent Form

Please read this form carefully and review as necessary. If you have problems reading it, ask to have it read to you.

I have voluntarily entered into the healthcare decision making process with Thomas Cook, MD (“Dr. Cook”), and have spoken with Dr. Cook, who has recommended that I (my child) receive(s) medication(s) and/or psychotherapy. Dr. Cook has advised me of the medications that are known to be of help in treating symptoms such as mine, and the reasons for taking them. Dr. Cook discussed the risks and benefits of such medications and the likelihood of improvement or no improvement with or without medication. Reasonable treatment alternatives, if any, have been discussed. No promise or guarantee has been made to me as to a resulting cure. Dr. Cook advised me of the potential side effects of the medications prescribed to me from the groups below. I understand that I have the right to accept or refuse medications recommended to me. I understand that my consent to treatment may be withdrawn at any time by stating such intention in writing to Dr. Cook’s Office. I understand that medications may have side-effects that are unexpected or that are not on this list, and that if I have any further questions or want to know more about my medications I can ask for more information. The side effects include, but are not limited to:

Antipsychotics - (e.g., Abilify, Risperidone, Seroquel, Geodon) Drowsiness, stiffness, muscle spasms, tremors, restlessness, dry mouth, constipation, blurry vision, uncontrollable movements or development of tardive dyskinesia, weight gain, increased risk for diabetes or elevated lipids or cholesterol, lightheadedness, drooling, worsening seizures, changes in blood pressure, difficulty with discontinuation.

Antidepressants - (e.g., Celexa, Zoloft, Lexapro, Prozac, Selegiline, Remeron, Cymbalta, Wellbutrin, Emsam) Dry mouth, constipation, drowsiness, lightheadedness, heart arrhythmia, nausea, diarrhea, decreased sex drive and function, headache, shakiness, restlessness, unsteadiness, weight gain, worsening seizures, changes in blood pressure, development of tolerance, psychological or physical dependence, difficulty with discontinuation.

Mood Stabilizers / Anticonvulsants – (e.g., Lithium, Depakote, Tegretol, Lamictal, Topamax, Gabapentin, Lyrica) Sedation, slowed thinking, unsteadiness, nausea, diarrhea, constipation, drooling, increase in liver enzymes, lowering of blood count, severe rash, changes in blood pressure, increased thirst and urination, decrease in thyroid function, lowered blood pressure, numbness and tingling in limbs, kidney stones, development of tolerance, psychological or physical dependence, difficulty with discontinuation.

Sedatives / Anxiolytics – (e.g., Ativan, Xanax, Klonopin, Valium, Restoril, Ambien, Lunesta, Sonata) Sleepiness, lightheadedness, unsteadiness, confusion, learn vision, slurred speech, nasal congestion and dryness, dry mouth, constipation, development of tolerance, psychological or physical dependence, difficulty with discontinuation.

Stimulants - (e.g., Adderall, Ritalin, Concerta, Vyvanse) Constipation, coughing, diarrhea, dizziness, drowsiness, dry mouth, flushing, headache, loss of appetite, nausea, nervousness, restlessness, stomach pain or upset, sweating, trouble sleeping, unpleasant taste, vomiting, weakness, weight loss, development of tolerance, psychological dependence, difficulty with discontinuation.

Anti-Parkinson’s Drugs - (e.g., Cogentin, Artane) Dry mouth, constipation, worry vision, slow urination, excitation.

Beta Blockers - (e.g., Propranolol, Metoprolol) Dizziness, lightheadedness, tiredness, stomach pain, intense dreams, insomnia, slow heartbeat, fainting, impotence.

Muscle Relaxants - (e.g., Zanaflex, Baclofen, Flexeril, Gabapentin, Lyrica) Sleepiness, lightheadedness, unsteadiness, confusion, learn vision, slurred speech, nasal congestion and dryness, dry mouth, constipation, acid reflux, development of tolerance, psychological or physical dependence, difficulty with discontinuation.

Xyrem / Sodium Oxybate Nausea, vomiting, memory problems, depression, bedwetting, sleepwalking, headache, nasal congestion, physical discomfort, development of tolerance, psychological or physical dependence, difficulty with discontinuation.

I understand the dosage(s) and when to take the medication(s), and for how long, and that any changes in medication dosage and/ or frequency during the course of treatment will be discussed with me. I recognize that unforeseen events and conditions arising during the course of treatment may necessitate surgical or medical care, restriction of activity, physical control, or seclusion. I authorize Dr. Cook and Happy Happy Happy, LLC (collectively, “Dr. Cook’s Practice”), to carry out such emergency measures. I understand that I should promptly inform my psychiatrist about possible adverse reactions or alarming changes in my condition, e.g., sudden suicidal or violent thoughts or tendencies, dizziness, severe sedation, fever, swollen lymph nodes, rash, abdominal pain and confusion, loose stools and hyperthermia, lightheadedness and confusion. If I (or the patient) am over 65 yrs old, and taking benzodiazepines, I understand Dr. Cook’s policy that this entails certain risks, and may usually only occur at low doses, and by my consenting to the small increased risks of falling down, or developing dementia.

No matter if I (or the patient) am elderly or not, I understand that Dr. Cook’s recommendation is not to drive, drink alcohol, or operate machinery while taking benzodiazepines or other sedatives. I understand that if the patient is a minor, and taking stimulants for long periods, there may be an effect on growth height. I understand that SSRI’s may lower platelets, and thereby increase the risk for bleeding, and that valproate as well as SSRI’s have been linked to low bone density and hair loss. I understand that I should inform my psychiatrist if I become pregnant, and/or if I am given any new medications prescribed for other conditions. I understand that mood stabilizers in particular may cause severe birth defects, and other medicines such as SSRI’s, may cause rare birth defects. With some anti-psychotics, I understand that there is a possible side effect, tardive dyskinesia, which may cause involuntary movement of the tongue, face, neck, limbs, or torso, and may persist even after stopping the medication. If I (or the patient) am over 65 yrs old and taking antipsychotics, I understand that such medicines may carry a small increased stroke risk.

I understand that the decision to take medication is up to me, but that I should always first discuss with my psychiatrist any decision to stop taking medication. I understand that when Dr. Cook orders refills of any medication for several months or more, this does not mean I do not need to be seen until they have all run out. I agree to take medication(s) only as prescribed, and I understand medications can only be prescribed reasonably and safely if I take them exactly as ordered by Dr. Cook, and that if I persistently and intentionally take medications prescribed by Dr. Cook in an irresponsible or dangerous way, I may be terminated as a patient in his practice.

Consent: my signature below confirms that the information on the form has been explained to me, I have received all the information I wanted about medication and treatment, and I give Dr. Cook’s Office permission to provide medication and treatment.

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June 15, 2022 6:52 pm CDT

Medication & Psychotherapy Consent Form Uploaded by BMH Front Desk - frontdesk@beyond-mh.com IP 66.68.60.75