5) I agree to work with the CSB staff responsible for conducting ongoing assessments of my mental status and associated risk factors. I understand that this may be conducted as part of case management visits, individual therapy appointments or a separate meeting as directed by the CSB. The CSB will provide qualified staff persons for the purpose of conducting mental status and risk factor assessments. The responsible person is and the frequency of my mental status assessment and risk assessment will be . 6) When applicable, I agree to participate in individual therapy or supportive counseling with treatment staff of the supervising CSB (or CSB designee). The initial schedule for my individual therapy is: Duration of Therapy: Frequency of Individual Sessions: Location of Therapy Sessions: 7) I agree to take psychotropic medication as recommended by my treating psychiatrist. I agree to meet with my treating psychiatrist (or psychiatrist's designee) at the supervising CSB (or CSB designee) for the purposes of monitoring my psychotropic medications and to have my prescriptions renewed and refilled. I will participate in psychiatric treatment for the duration of conditional release. Psychotropic medications: Location of meetings with psychiatrist: Frequency of meetings with psychiatrist: 8) I to submit to periodic blood or urine analysis as directed by treatment staff of the supervising CSB for the purposes of monitoring psychotropic medication compliance and tolerance. 9) I agree to receive recommended medical treatment for the duration of my conditional release. My current medical conditions and providers are listed below: My current medical condition(s) is: Name and office location of medical provider(s): 10) I agree to participate in the following substance abuse service(s): Type of substance abuse service(s): Provider and location of substance abuse service(s): Frequency of substance abuse service(s): Duration of substance abuse service(s): 11) I agree to submit to random and/or periodic breathalyzer, blood or urine analysis as directed by treatment staff of the supervising CSB for purposes of monitoring alcohol consumption, illicit drug
5) I agree to work with the CSB staff responsible for conducting ongoing assessments of my mental status and associated risk factors. I understand that this may be conducted as part of case management visits, individual therapy appointments or a separate meeting as directed by the CSB. The CSB will provide qualified staff persons for the purpose of conducting mental status and risk factor assessments. The responsible person is and the frequency of my mental status assessment and risk assessment will be . 6) When applicable, I agree to participate in individual therapy or supportive counseling with treatment staff of the supervising CSB (or CSB designee). The initial schedule for my individual therapy is: Duration of Therapy: Frequency of Individual Sessions: Location of Therapy Sessions: 7) I agree to take psychotropic medication as recommended by my treating psychiatrist. I agree to meet with my treating psychiatrist (or psychiatrist's designee) at the supervising CSB (or CSB designee) for the purposes of monitoring my psychotropic medications and to have my prescriptions renewed and refilled. I will participate in psychiatric treatment for the duration of conditional release. Psychotropic medications: Location of meetings with psychiatrist: Frequency of meetings with psychiatrist: 8) I to submit to periodic blood or urine analysis as directed by treatment staff of the supervising CSB for the purposes of monitoring psychotropic medication compliance and tolerance. 9) I agree to receive recommended medical treatment for the duration of my conditional release. My current medical conditions and providers are listed below: My current medical condition(s) is: Name and office location of medical provider(s): 10) I agree to participate in the following substance abuse service(s): Type of substance abuse service(s): Provider and location of substance abuse service(s): Frequency of substance abuse service(s): Duration of substance abuse service(s): 11) I agree to submit to random and/or periodic breathalyzer, blood or urine analysis as directed by treatment staff of the supervising CSB for purposes of monitoring alcohol consumption, illicit drug
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