This agreement is to help the patient understand and comply with the laws regarding controlled pharmaceuticals: I understand and agree to the following:

  • If prescribed by my physicians, I have agreed to receive scheduled (controlled) medications. These medications are being prescribed to improve my functioning.

  • There is a known risk of psychological addiction and/or physical dependence associated with chronic use of controlled medications.

  • I will seek psychiatric treatment, psychotherapy, or other forms of treatment, if my provider deems it necessary.

  • I will communicate openly and fully the benefits and side effects of my medications.

  • I will NOT use any illegal substances during the course of this agreement.

  • I will NOT share my medications with anyone.

  • I will NOT attempt to obtain any controlled medications from another provider or by illegal means.

  • If I break this agreement, my provider may stop prescribing my controlled medications. He/she may taper my medications over  a period of days to avoid withdrawal symptoms. He/she may also refer me to a treatment facility.

  • I will safeguard my medication from loss, theft, or unintentional use by others. Lost/stolen medications may not be replaced. I will file a police report should my medication be stolen.

  • I authorize my provider and pharmacy to cooperate fully with any law enforcement agency in the investigation of possible misuse, sale, or other diversion of my medications.

  • I agree to submit to blood or urine tests if requested by my provider.

  • I understand my provider may verify I am receiving medications from only one provider through the Prescription Monitoring Program.

  • I agree to take my medications as prescribed. Taking my medications at a greater rate than prescribed will result in my being without medication for a period of time.


We would like to thank you for choosing Geenens Psychiatry, PA.  We know you have choices, and we value you and strive to provide the best care we can in the most comfortable setting.