Austin Psychiatric Alliance, PLLC 

CONSENT FOR TREATMENT

I give full consent for the completion of an evaluation and 

the provision of treatment as necessary until I otherwise 

notify AUSTIN PSYCHIATRIC ALLIANCE.

Signature: _____________________________   Date: __________

CONSENT FOR TREATMENT OF CHILDREN OR DEPENDENTS

I certify that I have legal responsibility for _________________

including the specific right to initiate mental health treatment 

on their behalf.  I give full consent of the completion of an 

evaluation and the provision of treatment as necessary 

until I otherwise notify AUSTIN PSYCHIATRIC ALLIANCE.

Signature: _____________________________   Date: __________ 

STATEMENT OF RIGHTS AND RESPONSIBILITIES FOR PATIENTS

I have read and understand the Statements of Rights and 

Responsibilities for Patients.  I am aware that I can also

request copies for my records after reading the posted notices.

Signature: ______________________________  Date: __________