This is an agreement between the patient and prescribing provider concerning the use of controlled substances (including, but not limited to, benzodiazepines and stimulants) for the treatment of medical condition(s) by Think Well. To comply with state and federal regulations, Think Well has developed the policy outlined in this agreement regarding the use of controlled substances. By signing this agreement, I confirm that I understand the risks and benefits of this class of medication and the policies of this practice regarding its use and agree to abide by these policies.

I understand that these medications carry risks, including dependence, misuse and potential side effects.

I understand and agree to the following policies of Think Well regarding the use of controlled substances (including, but not limited to, benzodiazepines and stimulants):

1. I agree to obtain benzodiazepine and stimulant prescriptions from one provider and only one provider. I understand that if there is evidence of these medications being obtained or requested from another source, no further prescriptions will be written and I will be discharged from the clinic.

2. I will attend all scheduled appointments at Think Well.

3. I will communicate with other providers who are treating me that I am under a controlled substance agreement with the prescribing provider.

4. I consent to the release of this agreement information to other providers, emergency departments, pharmacies and consultants and to allow pharmacies to release my prescription history. I also consent for other providers, emergency departments, pharmacies and consultants to report violations of this agreement to the prescribing provider and my primary care provider.

5. Each prescription will be written for a fixed amount of medication(s). I agree not to change the dosage of my above-mentioned medications. Dosage changes will be made only with approval of the prescribing provider. I understand that making my own changes in dosing are grounds for discontinuation of the medication and dismissal from the practice.

6. I will inform my provider of any other medications, supplements, or substances I am taking. I understand that the use of alcohol, illegal substances, or non-prescribed medications can increase the risk of controlled substances, including heart dysrhythmias, respiratory depression, and even death.

7. I understand that it is my responsibility to keep the medication in a secure place. If my medications are damaged, lost, or stolen, I understand that they will not be replaced.

8. I understand that if the prescribing provider or my primary care provider becomes concerned that there is illegal activity, he or she may notify the proper authorities including law enforcement.

9. Adverse reactions to prescribed medications should be reported to the office, which may result in a change in dosage or discontinuation of medication.

10. I understand that I can reduce the use of medications by leading a healthy lifestyle and will work with my provider to optimize my overall health.

11. The terms of this agreement will end with the termination of prescribed medication by the prescribing provider.

I have read the above agreement and terms for use of controlled substances (including, but not limited to, benzodiazepines and stimulants) as they pertain to my care. All of my questions about the above-mentioned medication use and the policies of this practice have been answered to my full satisfaction. I consent to treatment with controlled substances (including, but not limited to, benzodiazepines and stimulants) and will abide by this agreement and the policies of Think Well.