AFTC Consent for Psychiatric Consultation This field is hidden when viewing the formGUIDThis field is hidden when viewing the formreqCodeThis field is hidden when viewing the formuserEmail This field is hidden when viewing the formSubmission Date (Admin Only) DD slash MM slash YYYY Please review the following statements regarding your consultation with Aurora Family Therapy 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 Aurora Family Therapy Centre.(Required)I understand that a letter with any recommendations may be sent to my family physician.(Required)I have spoken with my therapist about the risks and benefits of a psychiatric consultation.(Required)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 Aurora Family Therapy Centre.(Required)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 Aurora 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(Required) DD slash MM slash YYYY Full Name(Required)Signature(Required)
