Eclipse Mental Health Services

Patient Name:

Date:

The following is required to fulfill your compliance requirements. Please initial after each statement demonstrating that you read and understand the requirement:

1. Attending ALL scheduled appointments. Please notify 24 hours in advance if you are not going to be able to make your appointment. No contact No show will not be tolerated. Payment is due at time of service.

2. Completing scheduled blood work and urine analysis is required to be scheduled for your follow up appointment with our providers.

3. Taking all medications as prescribed

4. The above will be demonstrated by confirmation urine screen. Compliance urines are 100% accurate. Arguing about your results can result in immediate dismissal.

5. Medication counts. You will need to bring your medication to all of your lab appointments.

6. Completing all additional requested task. Examples include Cognitive assessments or mental health screening tools

The Following NON-compliance may result in immediate dismissal or tapering/discontinuation of current medication regimen:

1. Not taking current medication as prescribed

2. Abusing any controlled dangerous substance

3. Abusing your current medication regimen

4. Taking medication not prescribed to you

5. Providing urine that is not your own

6. Providing urine that is not the correct temperature

7. No call No show

8. Rude or argumentative behavior

9. ANY threat towards my staff or myself

10. Repeated lost or stolen medication. You will only be allowed 1 refill related to this occurrence. Your medications are YOUR responsibility

If any compliance requirement is violated you will be required to review and sign a compliance violation log. If you refuse to do this you will be dismissed immediately.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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