AFTC Consent for Psychiatric Consultation Form Resilia Consent for Psychiatric Consultation Este campo está oculto cuando se visualiza el formularioGUIDEste campo está oculto cuando se visualiza el formularioreqCodeEste campo está oculto cuando se visualiza el formulariouserEmail Este campo está oculto cuando se visualiza el formularioSubmission Date (Admin Only) DD barra MM barra AAAA Please review the following statements regarding your consultation with Resilia Community Wellness Centre's Psychiatrist, Dr. Peter Czaplinski. Please enter your initial after each statement if you agree.I understand that I am participating in a consultation with psychiatrist, Dr. Peter Czaplinski for the purpose of assisting my therapy at Resilia Community Wellness Centre.(Obligatorio)I understand that a letter with any recommendations may be sent to my family physician.(Obligatorio)I have spoken with my therapist about the risks and benefits of a psychiatric consultation.(Obligatorio)I consent to my therapist, the Director of Mental Health Services and Dr. Czaplinski exchanging any relevant information to assist in the consultation and my therapy at Resilia Community Wellness Centre.(Obligatorio)Alternatively, if the person is not able to read and understand this document (in English) and as a result is not comfortable (agreeing) to sign, the person can provide verbal consent by stating in the person’s own language “I agree to consent to a consultation with Dr. Czaplinski and accept the terms and conditions of the Consent to Psychiatric Consultation Form”. The Clinician and other Resilia Staff and/or interpreter by signing this document are confirming the person understood what was explained and that the person is agreeing to consent and the person accepts the terms and conditions of the Consent to Psychiatric Consultation Form. Please have the interpreter enter their name below attesting they have interpreter the above information to the client.Date Signed(Obligatorio) DD barra MM barra AAAA Full Name(Obligatorio)Firma(Obligatorio)
