This is to help you understand your rights and responsibilities and the level of cooperation that we need from you in order to help you realize the highest level of mental and emotional health of which you are uniquely capable. Our desire is to form a partnership with you regarding your mental health. Your assistance is crucial and the interest and commitment that you bring to this partnership are essential to attaining significant improvement or resolution to your mental health concerns.
You are assured the following rights:
-The right to be treated with dignity and respect
-The right to treatment including access to medical care and habilitation, regardless of your race, religion, gender, ethnicity, age, or sexual orientation.
-The right to have your treatment and other patient information kept private.
-The right to know about all your treatment choices, regardless of the cost of those treatment choices, and to participate in the choice of treatment.
-The right to consent or to refuse treatment,consent can be withdrawn at any time.
-The right to obtain a copy of your treatment plan by completing a release form.
-The right to contact Disability Rights of North Carolina at 919-856-2195.
In order to provide you with the best care, your commitment to your treatment and recover is essential. We require that patients’ understand their role and responsibilities in their care:
-You have the responsibility to give your provider the information needed so that we can delver the best possible care.
-You have the responsibility to let your treating provider know if or when the treatment plan no longer works for you.
-You have the responsibility to follow your medication plan. You must tell your treating provider about any medication changes, including medications prescribed for you by other healthcare professionals.
-You have the responsibility to keep your scheduled appointments.
-You have the responsibility to ask your treating provider any questions you may have about your care, so that you can better understand your care and the role you play in your care.
-You have the responsibility to follow your treatment plan and instructions for your care, once that care has been agreed upon by you and your treating provider.
By signing below, you acknowledge that you fully understand your rights and responsibilities, and that you consent for care and treatment by Carolina Complete Psychiatry, PLLC.
I have read and fully understand my rights and responsibilities in my partnership with Carolina Complete Psychiatry, PLLC in providing for my care, and agree to adhere to them, and acknowledge that I have received a copy of this statement. Further, I hereby consent to outpatient treatment and give permission for the clinician to provide the services deemed necessary or advisable in the diagnosis and treatment of the patient. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made as to the result of treatment received by Carolina Complete Psychiatry, PLLC. I understand that the patient has the right to without consent to any medical service that is deemed necessary or advisable by the clinician. My signature below indicates my understanding and approval of the above.