Clinical Forms — Legacy Behavioral Health Center

Medication Collaboration Tools

Choose the tool that matches the patient's age group. Complete it together during the visit — a PDF copy is generated and emailed to the clinic automatically.

Ages 3–11

My Medicine Choice Menu

Hi! We want to help your brain and body feel great so you can do your favorite things, like play, learn, and sleep well. You get a say in how you take your medicine! Fill this out with your doctor and parent.

About me

Name

Today's date

1. What do I want medicine to help me with the most?

Circle your biggest goal!

Making school or homework feel easier Having more energy for sports and playing Falling asleep easily and having good dreams Making my mind feel calmer and less worried Getting along better with my family and friends

2. How do I like to take medicine?

Check your favorite way

A liquid that tastes like fruit A chewable tablet that I can crunch A powder or capsule opened up and sprinkled into applesauce, pudding, or yogurt A tiny pill that I can swallow fast with a big gulp of water or juice

3. My Medicine Routine Rules

Pick your favorites

When should I take it?

Right after breakfast Right before bedtime Right when I come home from school

What is my favorite "chaser" or reward after taking it?

A sip of my favorite juice A high-five or a special sticker Watching 5 minutes of my favorite show

My Promise I promise: I will tell my parent or doctor right away if my tummy hurts, if I feel too sleepy, or if I feel any weird changes in my body.

Signatures

Type the child's full name as an electronic signature.

Child's signature *

Parent's initials

Ages 12–17

Shared Medication Trial Agreement

A three-party shared risk & autonomy contract. Use when an adolescent requests a medication change that carries clinical risk — instead of a flat refusal, document a structured, mutually agreed-upon 4-week trial.

1. The Core Purpose

Adolescent's name

Requested medication change

The clinical team and caregiver(s) recognize the adolescent's growing autonomy and desire to manage their own health. In return, the adolescent recognizes that changes must be monitored closely to ensure safety, academic success, and emotional well-being.

2. The Trial Period (4 weeks)

Start date

End date

Follow-up appointment (locked in)

3. Roles and Responsibilities

The Adolescent: agrees to take the medication exactly as adjusted every single day, and not to make further changes without calling the clinic first.

The Caregiver: agrees to step back from daily micro-managing or arguing about the medication, acting instead as a supportive observer, and to respect the adolescent's ownership of this trial.

The Clinician: agrees to authorize this trial dose, monitor clinical safety, and refrain from judging the adolescent if symptoms fluctuate.

4. Safety Guardrails & Relapse Indicators

If any "Red Flags" occur, the adjusted plan is not fully supporting the adolescent's mental health — contact the clinic to re-adjust.

Green Light — going well

Sleeping 7–9 hours a night
Attending school/activities
Stable, manageable moods

Yellow Light — call clinic

Missing school days due to mood
Sleep patterns changing heavily
Friends/family notice high irritability

Red Light — previous dose & call immediately

Thoughts of self-harm or suicide
Complete withdrawal from everyone
Intense, unmanageable panic or rage

5. Signatures of Agreement

By signing below, we agree to honor this trial, communicate honestly, and prioritize safety above all else. Type your full name as an electronic signature.

Adolescent signature *

Date

Caregiver signature *

Date

Clinician signature *

Date

✓

Form submitted

Thank you! A PDF copy of this form has been generated and emailed to the clinic.