Should You Use This Form?

• This form constitutes an Agreement between yourself, your primary therapist, and Ron Sterling, M.D., for the purpose of either:
  • Providing a medication evaluation of you to you and your primary therapist; or,

  • Providing a medication evaluation and recommendation and prescribing medication or managing previously-prescribed medication, and consulting with your primary therapist about the treatment plan.

• This explanation is provided to you only to help you understand the use of this form, not to interpret it, nor to amend it or alter its meaning in any way, whatsoever.

• If you or your primary therapist wish to fill this form out before arriving at Dr. Sterling's office, you may print it out, fill in the requested information, sign it, and deliver it when you see Dr. Sterling for your appointment.

Re: _______________________________________________
         Client's Name

The above client has requested that I manage her/his psychiatric medications while concurrently seeing you for psychotherapy and other services. This Agreement will help facilitate treatment by clarifying our respective roles and communications and ensuring that the client understands them. (This form can also be found online at www.dearshrink.com/collaboration.htm.)

Consents to Release Confidential Information. We will each obtain consents from the client for releasing confidential information to each other. Anything revealed to you or I by the client that we think may be relevant to the treatment being rendered by each of us should be communicated.

Primary Therapist; Emergencies. Since you will likely be in more frequent contact with the client, it is my understanding that you will be, or you will provide the client with, a primary emergency contact. I encourage you to contact me as needed in any emergency. Although I am generally very accessible, the client should initially contact me only in the case of emergencies involving medication questions or side effects or in the event that she/he is unable to reach you or someone provided by you for emergencies.

Prompt Communication; Termination. In addition, since good communication between us is important for the success of the client's treatment, we must agree to return each other's phone calls promptly, and to inform each other in a timely manner if the client fails to keep appointments or otherwise fails to comply with treatment recommendations. In the event that the client terminates with one of us, we should communicate that information to the other provider and should also ask the client to make an appointment with the other provider to review treatment and termination questions and concerns.

Collaborative but Independent Services. By signing this Agreement, the client is declaring that she/he understands that there is no supervisory or agency relationship between us. Each of us should feel free to offer feedback and recommendations to each other regarding treatment. Each of us is free to accept or reject the advice or recommendations made by the other. Each of us will bill the client for services separately. The continuation of this treatment relationship is contingent on each of us fulfilling the terms of this Agreement.

Please indicate your agreement by signing below and have the client sign at her/his earliest convenience. This Agreement may be executed in any number of counterparts, all of which together shall for all purposes constitute one Agreement, binding on all who sign. Thank you.

I have read this Agreement and understand and assent to its terms.

________________________________________ Dated: ______________
Ron Sterling, M.D.

I have read this Agreement and understand and assent to its terms.

_____________________________________________________________
(Print Name of Primary Therapist)

________________________________________ Dated: ______________
(Primary Therapist Signature and Date)

I have read and understand this Agreement.

________________________________________ Dated: ______________
(Client Signature and Date)