DR.J & COLLEAGUES
Consent to assessment and treatment at NW Counselling Hub, Lincoln
I understand that upon signing this document I have received and read Dr Jajawi’s Terms and Conditions provided to me and I agree with the following:
1. I understand that Dr Jajawi, his secretary and staff at NW Counselling Hub will take all necessary steps to protect my privacy and information.
2. I understand that Dr Jajawi may need to review, use and disclose information about me, my medical/psychiatric diagnosis and treatment to other professionals or care providers.
3. I give permission for Dr Jajawi to share information with my GP, the NHS and / or other Specialists, as required.
4. To the best of my knowledge, my physical and mental health history and status, has been accurately and fully disclosed to Dr Jajawi.
5. It is my responsibility to inform Dr Jajawi of any changes in my medical status, psychiatric/mental health status and social status.
6. I understand that Dr Jajawi will perform a full assessment and may request other investigations, as required.
7. I agree to the treatment plan and will follow the recommended treatment plan, as discussed with Dr Jajawi. I am aware that this may carry a risk of side-effects, withdrawal symptoms and possible other complications, if I do not comply with, or adhere to, his instructions and/or if I exceed the recommended prescribed dosages of medication.
8. I understand that it is at my discretion to stop treatment or investigations, however, if I decide to do so, I understand that this may carry serious risk of side-effects, withdrawal symptoms and/or other complications.
9. I understand that if I decide to stop treatment or the assessment process, I will be solely responsible for any further side-effects or risks due to premature discharge against medical advice.
10. I understand that Dr Jajawi is offering an Outpatient Consultation Service only, at NW Counselling Hub. Dr Jajawi is unable to treat patients in crisis, emergency or high-risk situations within, or outside working hours. If my mental health condition deteriorates, and I believe I am in an emergency or crisis situation, e.g. having suicidal thoughts, considering harm to myself, others, or to property, or if I am at risk from others, I will inform my relative/carer and contact the Lincolnshire NHS Crisis Team on 0303 123 4000, go to the nearest A&E, or call an Ambulance or Police on 999 or 111 for immediate support.