Consent for Treatment

  • Advanced Behavioral Counseling of Northern New Jersey, LLC

    55 Newton-Sparta Rd. Suite 103/104, Newton, NJ 07860

    (973) 579-9394

    NPI 1184878449

  • Date Format: MM slash DD slash YYYY
  • I. Informed Consent for Treatment

  • By typing my name in the above input box, I certify that I am at least 18 years of age, and I consent to the rendering of such evaluation and treatment by: ABCNNJ, LLC and their associates located at: 55 Newton-Sparta Road, Suite 103/104, Newton, NJ 07860. I am aware that clinical practice is not an exact science, and I acknowledge that no representations, guarantees or warranties have been made to me as to the result of any evaluation or treatment procedure that I may receive. I understand that I will be medically treated by Deborah Drumm/Doreen Rasp/Kathleen Kilcoyne, who are advanced practice psychiatric nurses. In order to provide comprehensive care they may discuss confidential information about me. I also understand that I am responsible for fees that are not covered by my insurance.
  • II. Medication Consent Form

  • Deborah Drumm/Doreen Rasp/Kathleen Kilcoyne, has educated me regarding the medication that has been prescribed by her to (Please select one of the following):
  • If other, this is a person for whom I am the legal guardian and I consent to the administration of this medication. I have been educated regarding the possible side effects of this medication, possible drug and/or food interactions that may occur while taking this medication and the possible effects of this medication. If the person taking this medication becomes pregnant or is breast-feeding, I agree to discuss this prior/during treatment. I understand that Ms. Drumm and Ms. Rasp and Ms. Kilcoyne are psychiatric nurse practitioners who work in conjunction with each other, and in order to practice, they must discuss confidential information with each other and their collaborating psychiatrist, Dr. Sandra Squires, MD, located in Newton, NJ. I agree to electronic transfer of my medication records to her. I have also been informed of the reason or purpose of which this medication was prescribed.
  • III. Notice to all Advanced Behavioral Counseling Clients

  • There will be a cancellation/no show fee of $50.00 for any appointment not kept without notifying the office staff of Advanced Behavioral Counseling within a 24-hour period before the appointment. If the office is not open, you may leave a message on the answering machine.

    I have read and understand the above notice.