I __________________ parent / guardian of __________________ understand that:

(1) The type and extent of services that I will receive at Dr. Gautham’s Neuro Center will be determined following an initial assessment and discussion with me, my ward, and any other person(s), and may include lab, scans, and other investigations and reviews that the doctor determines as necessary to achieve the goal of determining the best course of treatment for my ward;

(2) Only a limited evaluation may be possible when my ward is uncooperative or absent, and that any diagnosis and treatment is based on such limited examination may sometimes be erroneous;

(3) Typically, treatment is provided over the course of several weeks or longer and the duration depends on the progress of my ward and my cooperation;

(4) During the course of treatment it may be necessary for the doctor to communicate with others who may be required to provide more information or support for diagnosis and treatment;

(5) While medication and/or therapy may provide significant benefits, it may also pose some risks;

(6) My ward may require admission for treatment and I agree for such admission to a hospital of Dr. Gautham’s choice;

(7) Medications and other treatments may have side effects and I accept responsibility for the same and will not hold Dr. Gauthamdas Udipi or his designee liable;

(8) Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories;

(9) I have to keep Dr. Gautham informed of any new symptoms that develop during the treatment so that the doctor can evaluate whether it is an effect or side effect and manage it accordingly;

(10) There may be some issues disclosed by my ward during consultation, and which may not be divulged to me in the interest of the well-being of my ward;

(11) I understand that treatment package includes doctor’s consultation, medicines, counselling, therapy, and testing as required and by paying the charges I agree to them;