Your physician may prescribe psychotropic medication(s). In order to make an informed decision, you must be provided with information (verbal and/or written) including the following:

1. The nature of your psychiatric condition (diagnosis).

2. The reasons for taking such medication(s), include the likelihood of improving or not improving without such medication(s).

3. The name, dosage, frequency, route of administration and duration of prescribed medication(s).

4. The possible side effects of the medication(s) known to commonly occur and may possibly cause birth defects, and any particular side effects likely to occur in your particular case.

5. The possible additional side effects which may occur with continued administration of an antipsychotic medication(s) if taken for more than three (3) months. Side effects may include persistent involuntary movements of the face, mouth, limbs, and trunk, called tardive dyskinesia. These symptoms may be irreversible and may continue to appear even after the medication(s) has been discontinued. Your physician will tell you if this possible side effects does not apply to the medication recommended for you.

6. Recommendations regarding the continuation and duration of medication(s) usage.

It is important that you also understand potential reasonable alternative treatments, including but not limited to:

1. Psychotherapy

2. Other Medications

3. Neurostimulation modalities (Transcranial Magnetic Stimulation, Electroconvulsive therapy, Neurofeedback)

4. Surgical modalities (Vagus Nerve Stimulation, Deep Brain Stimulation)

5. IV Ketamine

6. Acupuncture, supplements Your signature below acknowledges that you have read and agree to the foregoing. The medication(s) and alternative treatments have been adequately explained and discussed with you. You have received all of the information you desire concerning the medications and treatment. You understand that you are not obligated to continue treatment at Neuro Wellness Spa and you may seek additional information and treatment elsewhere. You authorize and consent to treatment to the administration of psychotropic medications. You may withdraw this consent, in writing, at any time by submitting your written statement to any member of the treatment team.

You consent to treatment with psychotropic medications after the medication(s) and alternative treatments have been adequately discussed with you. You understand that you are not obligated to continue treatment at Neuro Wellness Spa and you may seek additional information and treatment elsewhere. You may withdraw this consent, in writing, at any time by submitting your written statement to any member of the treatment team.