Adolescent Behavioral Health Consent Form
Adolescent Information
Full Name
Date of Birth
Address
Phone Number
School
Parent/Guardian Information
Parent/Guardian Name
Relationship
Phone Number
Email
Consent for Evaluation and Treatment
I have read and understand the information provided about the adolescent behavioral health services and consent to evaluation and/or treatment.
Confidentiality
Emergency Contact
Name
Relationship
Phone Number
Signature of Parent/Guardian
Date
Signature of Adolescent
Date