CONSENT FORM | Social Skills Clinic

Informed Consent for Child and Adolescent Psychiatry Services

You must read, sign and submit this form. Thank you!

Practice Name: Social Skills Clinic

Address: Nuffield Cambridge Hospital, Nuffield Health Cambridge Hospital, 4 Trumpington Rd, Cambridge CB2 8AF

Psychiatrist's Information:

Dr Shimrit Ilana Ziv, MD

Consultant Child and Adolescent Psychiatrist

GMC Registration Number: 7464666

Patient's Full Name

Parent/Guardian's Email

Parent/Guardian's Full Name

Patient's Date of Birth

This consent form outlines important information about the nature of the services, potential risks, benefits, and confidentiality. Please read carefully and fill in the required sections.

Nature of Services:

I understand that the services provided by Dr Shimrit Ziv may include psychiatric assessments, medication management, psychoeducation, social skills advice, psychotherapy, and other therapeutic interventions designed to address the mental health needs of my child.

Benefits:

I acknowledge that the benefits of these services may include improved mental health, enhanced coping skills, and overall well-being for my child. The goal is to collaboratively work towards achieving optimal mental health.

Risks:

I am aware that, as with any medical or psychiatric intervention, there may be risks and potential side effects associated with medications or therapeutic interventions. Dr. Shimrit Ziv will thoroughly discuss these risks, benefits, and alternative treatment options with me before any decisions are made.

Confidentiality:

I understand that maintaining the confidentiality of my child's health information is a priority. However, I acknowledge that there are legal and ethical exceptions to confidentiality, including situations involving harm to self or others, child protection concerns, or as required by law.

Treatment Plan:

I will be informed of the proposed treatment plan, including the rationale for any recommended interventions. Any adjustments to the treatment plan will be discussed with me in advance, and my input will be considered.

Emergency Procedures:

I understand that Dr Shimrit Ziv does not offer emergency services within the independent practice. Please see Crisis Resources & Information

Duration and Termination of Services:

I have the right to terminate services at any time. Dr Shimrit Ziv also reserves the right to terminate services if it is deemed clinically appropriate, and reasonable notice will be provided.

I have read and understood the Privacy Policy

Cancellation:

I understand there is a 24-hour cancellation policy for appointments. Refer to the Cancellation Policy for more details.

Consent Withdrawal:

I understand that I reserve the right to withdraw consent at any time.

Contact:

I agree to be contacted by the following methods:

Email / Phone / Video Conferencing Software (i.e., Zoom).

I, the undersigned parent or legal guardian, hereby provide informed consent for the psychiatric evaluation and treatment services for my child by Dr Shimrit Ziv.

I have read and understand the information provided in this informed consent form. I have had the opportunity to ask questions, and any concerns have been addressed to my satisfaction.

Yes

Parent/Guardian Name:

Your Signature

Select a date

I declare that the infomation I’ve provided is accurate & complete

Thanks for completing the consent form!