Behavioral Health Providers Treatment Of A Minor Consent Form

Please fill out as much of the following Behavioral Health Providers Treatment Of A Minor Consent Form as you can.

Behavioral Health Providers will only use the information you provide on the Treatment Of A Minor Consent Form for our records so we have proof of your consent to treat your child.

Click here for our privacy policy on data and healthcare information

We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Permission to provide mental health treatment to a minor

Thank you for choosing Behavioral Health Providers.

Treating a minor has its own concerns and responsibilities.

Please use the following form to indicate, that as the parent or guardian of a minor, you are aware of the intended treatment of your child and consent to this treatment. This form also requires the signature of an adult witness to your consent.

When satisfied with your responses on this form hit the Submit button below to return this form to Behavioral Health Providers.

Patient (Minor's) Information

Name of Patient (Minor) *

First

Middle

Last

Parent or Guardian Information

Name of Parent or Guardian *

First

Middle

Last

Parent or Guardian Email *

Parent or Guardian Signature *

Clear Signature

I hereby grant my permission for my son or daughter to be treated by Behavioral Health Providers, P.C. This permission will remain in force until revoked by the individual signing this document as “Parent or Guardian”.

Today's Date *

Adult Witness Signature

18+ year old Witness Signature *