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Admission Checklist
Authorization and Consent
Authorization for Use of Image
Authorization for Use or Release of Information
Belongings List
Consent for Ordinary and Routine Medical and Dental Care
Consent For Services
Consent for Treatment
Geriatric Depression Scale
Inpatient Certificate
Intake Questionnaire
Legal Notice to Patients
Notice Regarding Rights of Recipients
Observation Record
Patient Phone and Visitation Restriction Sheet
Petition For Involuntary/Judicial Admission
Psychiatric Medical Clearance Checklist
Psychotropic Medication Notice and Consent
Rights Receiving Mental Health Services
Suicide Safety Plan
Unit Rules

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Consent for Treatment

Patient

PATIENT IS UNABLE TO CONSENT OR IS A MINOR

Person Authorized

Full Name:

Relationship to Patient:

Street Address:

City:

State:

Zip Code:

Telephone:

NEED INTERPRETER?