Mental Health Treatment Minor Consent Form

Minor Information

Full Name

Date of Birth

Age

Address

Parent/Guardian Information

Full Name Relationship to Minor Phone Number

Consent

I hereby provide consent for the minor named above to receive mental health assessment, counseling, psychotherapy, or related services from the provider or facility below.

Provider/Facility Name

Limitations/Conditions (if any)

Additional Comments

Signatures

Parent/Guardian Signature

Date

Minor Signature (if applicable)

Date