Behavioral Health Consent for Minor

Minor Information

Full Name:

Date of Birth:

Address:

Parent/Guardian Information

Full Name:

Relationship to Minor:

Phone Number:

Consent

I hereby give consent for the above-named minor to receive behavioral health evaluation, counseling, and treatment as deemed necessary by the provider. I understand the nature, purpose, risks, and benefits of the services provided and have had the opportunity to ask questions.

Additional Information

Signatures

Parent/Guardian Signature: Date:

Provider Signature: Date: