I, the undersigned, for myself, hereby consent for psychiatric evaluation, psychiatric care and treatment as ordered/recommended by the provider at Austin Mind and Behavioral Health. This consent is provided for provision of outpatient services, office visits and ongoing outpatient care. I consent to provision of services by a midlevel provider (Nurse Practitioner or Physician Assistant), under the direction of the psychiatrist. I acknowledge that no guarantees have been made to me by the providers in this clinic, as to the results and of improvement in my condition.
I acknowledge that I have the right to discuss the assessment, potential risks, and benefits of any recommended treatment.