CONSENT FOR VOLUNTARY INPATIENT TREATMENT NAME OF PATIENT NAME OF COUNTY PROGRAM NAME OF FACILITY LAST FIRST NAME OF BASE SERVICE UNIT ADMISSIONS DATE MIDDLE AGE SEX BASE SERVICE UNIT NUMBER ADMISSIONS NUMBER INSTRUCTIONS BEFORE SIGNING THIS FORM, YOUR TREATMENT SHOULD BE EXPLAINED TO YOU AND YOU MUST BE GIVEN A COPY OF THE PATIENT'S BILL OF RIGHTS. THE REPORT OF YOUR INITIAL EVALUATION AND THE PROPOSED TREATMENT PLAN MUST BE COMPLETED AND SIGNED BY YOU AND THE PHYSICIAN. VOLUNTARY CONSENT TO INPATIENT TREATMENT For the above-named person who is: � � an adult 18 years of age or older or a person who is at least 14 years of age and not yet 18 years old I consent to the treatment which has been explained to me including the types of medication, examination procedures and the types of restrictions which are applicable; and I understand that in order to leave before I am discharged, I must give those in charge of my treatment; and (UP TO 72) hours advance notice in writing to I confirm that my rights and responsibilities while a patient in this hospital have been explained to me. SIGNATURE OF PATIENT DATE OF SIGNATURE For the above-named person who is: � under 14 years of age I consent to the treatment of my child or ward which has been explained to me including the types of medication, examination procedures and the types of restrictions which are applicable; and I understand that in order to take my child or ward out of the hospital before he or she is discharged, I must give hours advance notice in writing to those in charge of the patient's treatment; and (UP TO 72) I confirm that the rights and responsibilities for myself and my child or ward while a patient in this hospital have been explained to me. SIGNATURE OF: DATE OF SIGNATURE � � PARENT OR GUARDIAN PRINT NAME OF PERSON SIGNING ABOVE PAGE 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com MH 781 5/14 INITIAL EVALUATION AND TREATMENT PLAN INITIAL FINDINGS: DESCRIPTION OF PROPOSED TREATMENT PLAN: DESCRIPTION OF PROPOSED RESTRICTIONS AND RESTRAINTS: SIGNATURE OF PHYSICIAN/DATE SIGNATURE OF CLIENT/PARENT/OR GUARDIAN/DATE Any person who knowingly provides any false information when he/she completes this form may be subject to prosecution. PAGE 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com MH 781 5/14