Patients must give voluntary consent for mental health treatment. Your signature (or that of your legal guardian) will demonstrate consent for receiving mental health treatment from the Petit Psychiatry. I voluntarily consent to mental health treatment as performed by the Petit Psychiatry and its employees. This treatment may include but not limited to: assessment, screening, consultation and recommendations, psychotherapy, holistic services and psychiatric medication management. I understand that mental health treatment may involve certain risks and benefits and I understand these risks and benefits. I also understand the risks and benefits of declining treatment. I am also, aware that I have the right to request information about alternative treatment options, should they exist. I have read the above information and I authorize the Petit Psychiatry to provide mental health services to myself or this patient (if guardian).

Acknowledgement of Receipt of Petit Psychiatry’s Policies By signing this agreement, you agree that you have read the Petit Psychiatry’s Policies and you agree to abide by its terms during our professional relationship. Please look at our website to review our annually updated policy form.

Acknowledgement of Receipt of Notice of Privacy Practices We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.

Consent Form for Communication of Protected Health Information I CONSENT to the communication for appointment reminders via text, email, or phone.

I have carefully reviewed this document. My signature indicates my full understanding and agreement of this document.