Parental Consent Form

Adolescent's Full Name: Date of Birth: Parent/Guardian Name: Relationship to Adolescent:

Program/Treatment Facility Name:

I, the undersigned parent/legal guardian, give my consent for my adolescent named above to participate in the Substance Abuse Treatment Program listed. I understand the nature and purpose of the services, and any questions regarding the program have been answered to my satisfaction.

I understand that all information will be kept confidential in accordance with applicable laws and regulations.

Parent/Guardian Signature: Date: