Conditions That May Lead to Treatment Modification or Termination
Patients are expected to communicate openly and honestly about any substance use, including illicit drugs, alcohol, and misuse of prescribed medications. These include medical or non-medical use (over the counter, herbal and alternative medicine, other drugs such as ketamine, kratom, cannabis, etc). This includes prior or current use, as well as update the provider of any future drug use during the treatment. Patients must understand that refusal to provide or falsification of information may jeopardize their treatment and may be life threatening due to possible drug interactions. Such actions may lead to termination of treatment. By signing this agreement, the patient acknowledges understanding of these policies and commits to working collaboratively with the provider. This agreement is designed to support successful treatment engagement, provide optimal clinical care, support treatment continuation, and ensure the safety of all patients.
I understand my responsibilities and my provider’s responsibilities, and I have had the opportunity to ask questions prior to signing.
I understand that this agreement is designed to support my care and safety, and I understand the potential reasons treatment might be modified or discontinued.
I agree to work collaboratively with my healthcare team.