ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Page 1 of 2

MEDICATION CONSENT FORM (9 CCR Section 784.29 & 851)

This form provides information regarding recommended medications(s) to support a client’s mental health and is not a contract to
force medication use against a client’s will. This form may not cover all the uses or possible side effects of a client’s treatment.

Client name: _______________________________ DOB:________________ PSP:__________________

1. Medications are recommended for treating bothersome symptoms. The following symptom(s) I am experiencing is/are the
reason(s) my medication(s) is/are recommended for me:

 Lack of energy or motivation  Aggression or hostility  Difficulty organizing thoughts

 Depressed mood  Mood swings  Difficulty communicating well with others
 Poor appetite or over eating  Rapid thoughts  Hyperactivity
 Difficulty concentrating or easily confused  Impulsive behaviors  Panic attacks
 Difficulty sleeping or sleeping too much  Unwanted thoughts  Nightmares or flashbacks
 Anxiety or constant worrying  Fixed beliefs  Muscle stiffness or spasms
 Difficulty coping with stress  Fearful feelings or unrealistic fears  Restlessness
 Irritability or agitation  Visions or voices others can’t see or hear  Other: _______________

Medication Name Medication Type (Class of Med) Administered by (Route): Daily Dose (Range): Frequency (Range):
□ Antidepressant □ Anti-Anxiety □ Antipsychotic □ Mouth □ Injection
□ Mood Stabilizer □ Psychostimulant □ Anti-EPSE □ Oher (specify):
□ Other (specify):
□ Antidepressant □ Anti-Anxiety □ Antipsychotic □ Mouth □ Injection
□ Mood Stabilizer □ Psychostimulant □ Anti-EPSE □ Oher (specify):
□ Other (specify):
□ Antidepressant □ Anti-Anxiety □ Antipsychotic □ Mouth □ Injection
□ Mood Stabilizer □ Psychostimulant □ Anti-EPSE □ Oher (specify):
□ Other (specify):
□ Antidepressant □ Anti-Anxiety □ Antipsychotic □ Mouth □ Injection
□ Mood Stabilizer □ Psychostimulant □ Anti-EPSE □ Oher (specify):
□ Other (specify):
□ Antidepressant □ Anti-Anxiety □ Antipsychotic □ Mouth □ Injection
□ Mood Stabilizer □ Psychostimulant □ Anti-EPSE □ Oher (specify):
□ Other (specify):

2. My need for this medication will be evaluated every visit. It is common to continue taking medications after the symptoms have
gone away to prevent the symptoms from coming back. It is estimated that I will be prescribed these medications for at least:

 6 months or longer  12 months or longer  Other:___________________

3. Additional and alternative treatment options deemed reasonable for my condition include:

 Psychotherapy  Group or family therapy  Other medications  Other:____________

4. Side effects, including probable and possible long-term (more than 3 months) side effects, are listed on the back of this form or
provided separately.

5. I have been offered and discussed medication information to my satisfaction and understand the importance of:
 Talking to my prescriber if I wish to stop medications in order to discuss the possible effects from stopping medications,
 Lab tests or other assessments performed at least once a year to monitor my progress and risk of experiencing side effects,
 Talking to my prescriber if I plan to or become pregnant or breast feed as many medications can cause birth defects.

6. I have been offered a copy of this medication consent form and understand I have the right to ask for additional medication
information, refuse to take medication(s) and I may withdraw this consent at any time.

Client’s or Substitute Decision Maker’s Signature: Relationship to Client: Date:

Prescriber’s Signature: □ Psychiatrist (MD/DO) Date:

□ Psychiatric Nurse Practitioner (PNP)
□ Physician Assistant (PA)
Staff Witness (if patient agrees but chooses not to sign): Date:
 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES Page 2 of 2
MEDICATION CONSENT FORM (9 CCR Section 784.29 & 851)
This is not a complete list of the possible side effects and risks associated with each medication. Consult a healthcare professional to
obtain additional information. Talk to your prescriber about ways to prevent or manage all side effects.

Common Side Effects for All How to Prevent or Manage Probable Side Effects
Upset Stomach Take the medication with food unless directed otherwise by your prescriber
Constipation or diarrhea Drink plenty of water, exercise, and eat foods high in fiber (ex: fruits and veggies, whole grains,
oatmeal, and others)
Dry mouth Drink plenty of water, eat a healthy snack or occasionally suck on a sugar-free candy
Drowsiness/fatigue Ask your prescriber if it is okay to take your medication(s) at bedtime
Headache Usually goes away within a few days. Drink water and talk to your prescriber if the headache does
not go away

Medication or Class Probable Side Effects Possible Long-Term Side Effects (More than 3 months)
 Antipsychotics Muscle spasms, restlessness, weight gain, Repeated movements of muscles of the face, mouth,
increase blood sugar or cholesterol arms, legs or torso and may appear after the
antipsychotic is stopped
Females: Increases a hormone that can lead to
missed menstrual cycle or milk production

Males: Increases a hormone that can lead to

increased fat tissue around breast or decreased
desire for sex
 Antidepressants Temporary jittery feeling when first started or Males: delayed ejaculation
with a dose increase Females: difficulty having an orgasm

If stopped suddenly: flu-like symptoms, brain

zaps or shock-like feelings
 Mood Stabilizers
o Valproate derivatives Rash, dizziness, unsteadiness, blurred or double Abnormal blood counts or sodium, missed menstrual
o Carbamazepine vision, weight gain cycle, hair loss or increased body hair.
o Oxcarbazepine
o Lamotrigine
 Mood Stabilizers
o Lithium Increased thirst and urination, acne, tremor Lowers thyroid or kidney function
 Psychostimulant Fast heartbeat, anxiety, reduced appetite, weight Delayed growth, lower sex drive
loss, irritability, trouble falling asleep
 Sleep, Anti-Anxiety, or Anti-EPSE Agents
o Benzodiazepine Weakness or fatigue, unsteadiness, dizziness, Memory difficulties, habit forming
o Nonbenzodiazepine hang over effects, risk of falls, unusual dreams,
(Z-drug) sleep eating or driving
o Buspirone Dizziness, jittery or restless feeling, difficulty Well tolerated
sleeping, confusion, blurred vision
o Gabapentin Fatigue, dizziness, blurred vision Weight change, leg swelling
o Pregabalin
o Hydroxyzine Dizziness, fatigue, sleepiness, difficulty Memory difficulties or clouded thoughts
o Diphenhydramine concentrating, blurred or double vision,
o Benztropine difficulty urinating
o Propranolol Fatigue, dizziness, lowers blood pressure and Lower blood pressure and heart rate
heart rate

□ Other Medication Additional Medication Information Sheets Offered? □ Yes, provided to client □ Yes, client declined
Medication names: Probable Side Effects Possible Long-Term Side Effects (More than 3 months)

Client’s Initials or Substitute Decision Maker: Prescriber’s Initials: