Psychiatric Consent for 13-17yo

Your name (this is the patient or minor signing this form - it may not be signed by the parent or guardian)

Date of Birth

Date

Consent to Receive Care for Minors 13-17 years old - TO BE COMPLETED BY PATIENT

As our patient you can expect:

To be treated with respect, consideration and meet your individual needs.
That your patient information to be kept confidential unless specifically requested or indicated otherwise by law.
To receive care in a setting that does not practice any discrimination.
To be an active participant in your care, including receiving information about your condition and options for treatment.

Dr. Sastry can be reached by leaving a message with a staff member or on voicemail at (206) 524-5656 during regular office hours. It may take up to 48 hours to receive a response. Dr. Sastry DOES NOT communicate over email or social media.

If you are having an emergency please call the crisis line at 866-427-4747.

Appointments: Dr. Sastry reserves your appointment time for you. You also agree to be there on time and complete all forms before your appointment. There is a $75 late cancellation/no show/late cancel fee charged directly to the person with financial responsibility.

Who can we share information WITH NO limitations? (parents, therapist, etc.)

Who can we share information WITH LIMITATIONS? (parents, therapist, etc.)

What do you not want discussed or shared?

IF YOU DO NOT WANT DR. SASTRY TO SPEAK WITH YOUR PARENT OR GUARDIAN ABOUT YOUR CARE, TYPE YOUR NAME HERE:

I consent to receive Psychiatric care from Dr. Sastry. I understand that I can revoke this at any time. This can include psychotherapy, medication management, and coordination of care as directed by me. You may revoke (take back) your consent at any time by notifying Dr. Sastry or our office.

Signature of patient (minor)

Date