Consent to Treat a Minor "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.PATIENT (MINOR) INFORMATION Minor’s Full Name:Date of Birth* MM slash DD slash YYYY Age:Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PARENT / LEGAL GUARDIAN INFORMATIONFull Name:Relationship to Minor:Phone:Email: Address (if different): Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Government-Issued ID Verified: Yes No PURPOSE OF THIS CONSENT This document authorizes [INSERT PRACTICE NAME] (“the Practice”) to provide psychiatric evaluation and treatment to the above-named minor. I understand that: Individuals under age 18 are generally considered minors Consent for treatment is typically required from a parent or legal guardian Laws vary by state and by type of service (mental health, substance use, reproductive care, etc.) AUTHORITY TO CONSENT I certify that I have legal authority to consent to treatment as:AUTHORITY TO CONSENT Biological parent Adoptive parent Legal guardian (court-appointed) Other (specify): AUTHORITY TO CONSENT Other LEGAL CUSTODY AND DECISION-MAKING AUTHORITY I understand that: Legal custody (not physical custody) determines the authority to make healthcare decisions The Practice relies on the information provided by the parent/guardian unless legal documentation states otherwise Custody status: Joint legal custody Sole legal custody Legal guardianship Foster care / state custody Other (specify): Custody status otherRequired Documentation (if applicable) Court order Divorce decree Custody agreement Guardianship documentation Foster placement documentation The Practice may require documentation before initiating or continuing treatment. Good Faith Representation I certify that: I am providing accurate and complete information No court order exists that limits my ability to consent I will provide documentation upon request The Practice may rely on this information in good faith and is not responsible for undisclosed custody restrictions. CONSENT FOR TREATMENT I authorize the Practice to provide psychiatric services including: psychiatric evaluation diagnosis medication management psychotherapy or counseling care coordination referrals I understand that: treatment involves risks, benefits, and alternatives outcomes cannot be guaranteed treatment decisions are based on clinical judgment MINOR ASSENT I understand that: The provider will seek the minor’s assent when developmentally appropriate The minor may participate in treatment decisions Assent does not replace legal consent CONFIDENTIALITY AND PARENTAL ACCESS I understand that: Parents/guardians generally have access to the minor’s medical records However, certain services may be confidential depending on: state law type of service clinical judgment The provider may limit disclosure when: necessary to protect the therapeutic relationship required by law safety concerns arise MINOR CONSENT EXCEPTIONS I understand that minors may consent to certain services under state law, including: emancipated minor status mature minor doctrine (where applicable) specific services (e.g., mental health, substance use, reproductive care) The Practice follows applicable state law in determining consent requirements. DIVORCE, SEPARATION, AND MULTIPLE GUARDIANS I understand that: One parent may consent unless restricted by court order The Practice may request consent from both parents in certain situations The Practice does not mediate custody disputes I agree to notify the Practice of any custody changes. EMERGENCY TREATMENT I understand that: In emergencies, treatment may be provided without prior consent Emergency care may include referral to: emergency department crisis services inpatient psychiatric care TELEHEALTH (IF APPLICABLE) I understand that: Telehealth services may be used Identity verification may be required Consent may be obtained electronically COMMUNICATION AND CARE COORDINATION I authorize the Practice to: communicate with providers involved in the minor’s care coordinate treatment Additional authorization may be required for specific disclosures. FINANCIAL RESPONSIBILITY I understand that: I am financially responsible for services Insurance does not guarantee payment I am responsible for copays, deductibles, and uncovered services WITHDRAWAL OF CONSENT I understand that: I may withdraw consent in writing at any time Withdrawal does not apply to services already provided Withdrawal may impact the Practice’s ability to continue treatment VOLUNTARY CONSENT By signing below, I acknowledge that: I have legal authority to consent I have provided accurate custody information I understand risks, benefits, and limitations of treatment I had the opportunity to ask questions I voluntarily consent to treatment SignatureParent/Legal Guardian Name:Signature:*Date: MM slash DD slash YYYY Second Parent/Guardian (if required):Signature:Date: MM slash DD slash YYYY Minor (Assent, if appropriate):Signature:Date: MM slash DD slash YYYY Provider Name:SignatureDate MM slash DD slash YYYY
