Parental Consent for Substance Abuse Treatment
Minor's Information
Full Name
Date of Birth
Address
Parent/Legal Guardian Information
Full Name
Relationship to Minor
Phone Number
Email Address
Address (if different)
Treatment Provider Information
Facility/Provider Name
Address
Phone Number
Consent
I hereby give my consent for the above-named minor to receive substance abuse treatment from the above treatment provider.
Parent/Guardian Signature
Date