Consent for the Treatment of Minor(s) Form – Behavioral Health

NATIVE HEALTH BEHAVIORAL HEALTH PROGRAM

I understand that I can withdraw my consent to treatment at any time. I have had explained to me and understand my confidentiality rights as it pertains to my child and disclosure of their treatment information. I understand that some services may be provided by a Behavioral Health Technician or unlicensed professional who may be working toward graduate degrees in Psychology, Social Work, Marriage and Family Therapy, Nursing and/or Psychiatry and/or licensure under the direction of supervising clinical staff. Other conditions of treatment such as the risks, benefits, and alternatives to the proposed treatment have been explained to me to my satisfaction.
Patient Name*
Date of Birth*
MM slash DD slash YYYY
SSN*
Name of Parent/Legal Guardian*
Address*
Home Phone*
Other Phone
Best time to contact*
Parent/Legal Guardian Status*
- Legally Married
- Never Married (Single parent custody/sole decision-making authority)
- Divorced
- Traditional Marriage
- Tribal or Group Home Placement
- Reasonable effort to contact non-custodial guardian(s)
Custody
- Sole Custody (Sole decision-making authority)
- Joint Custody (Shared legal decision-making authority)
Reasonable effort to contact non-custodial guardian(s)*
I/We herby give my/our consent for treatment of the above named child.
First Name*
Last Name*
Relationship to patient*

(parent/legal guardian/conservator/other)
Date*
MM slash DD slash YYYY
Email*

NATIVE HEALTH BEHAVIORAL HEALTH PROGRAM