Submit
Cancel

Medication Management/Consulting Physician Agreement

Jewish Family and Career Services of Atlanta
4549 Chamblee Dunwoody Road
Phone 770.677.9389
Fax 770.677.9400
JFCS
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
To Our JF&CS Clients:
The following is prepared to assist you in effectively utilizing the agency’s medical consultation services.

• If you have a clinical therapist at JF&CS, that therapist is your primary clinical contact for all things involving your clinical care at JF&CS.  Please, DO NOT CONTACT THE CONSULTING PHYSICIAN DIRECTLY.
• Treatment team:  The therapist and consulting physician work closely together on your behalf.  In general, the role of the consulting physician is to determine whether you can benefit from medication along-side your “talk therapy.”  If this is determined to be the case, the consulting physician will be able to prescribe and monitor your medication.
• Medication:  If you agree to the recommendation for medication, the consulting physician will explain how you are to take the medication, its benefits and possible side effects.  Feel free to ask questions, so you are sure you understand what to expect.  If you have questions about dosage or side effects after the consultation appointment, you are to contact your therapist.  If necessary, the therapist will contact the consulting physician on your behalf.
• Part Time Status – Please note our consulting physician is here only 2 days a week.  He is not available when on vacation or on other days of the week.  With this in mind, please know that prescription refills will not be filled after hours or on weekends.  Your primary care physician may be able to provide a refill when consulting physician is not available (e.g. when consulting physician is not here over weekends, off days and vacation days).
• Psychiatric and neurological medications have unique properties.  Should you choose to stop taking your medication, it is very important that you discuss this IN ADVANCE with your therapist and the consulting physician, in order to understand possible adverse effects.
• Prescriptions are written to provide you with a sufficient supply of medication.  It is your responsibility to be sure that you do not run out.  If for some reason, you find that you need a refill before your next appointment you must contact your therapist at least ONE WEEK before you run out of medication.  The consulting physician will not be available for last minute refills.  We may not always be able to submit refills with a pharmacy on short notice.  Further, certain medications cannot be refilled via phone call.  We reserve the right to charge a fee for staff time involved in facilitating a refill if you have missed your regular appointment or require special services managing prescriptions.
• Appointments are booked and held for you.  You will receive a reminder notice for your appointment.  There will be a charge for any appointment not cancelled AT LEAST 24 hours in advance.  However, if you find you cannot keep an appointment, we would appreciate as much notice as you are able to give us.  Please be aware that once you cancel an appointment you may have to wait for a month or more for a new appointment.
• Medication consultation is available to clients of JF&CS during the time they are in treatment with one of our counselors.  Once you have completed a course of treatment your treatment team will discuss with you the best option for managing your medication should it be determined that it is necessary for you to remain on medication.
• Emergencies:  If you are experiencing an immediate health or mental health emergency, you may need to call 911 or go to the emergency room.  If you have IMMEDIATE NEED to speak to your therapist during regular business hours, such as concern about a possible medication side effect, please call our main number 770-677-9800 and inform the receptionist as to the urgency of your being put in contact with the therapist.  The agency maintains an after-hours emergency number you can access by calling 770-677-9300 and following the prompts.

Thank you for your confidence in JF&CS.  We appreciate being of assistance to you.

I have read and received a copy of the above information:
* Acknowledgement:
* Signature
Signer Type:
Name:
Signature:
Sign with Touch
 
Comments:
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.