Consent to Treat Minor Form

The Consent to Treat Minor Packet serves as a legal document that grants permission for the BPB Counseling provider to treat your child/minor. This form is required before sessions can begin. In split custody arrangement, both parents are required to complete a consent to treatment submission. This ensures that the clinician has the authorization to provide appropriate care for minors, while also protecting their rights and well-being.

Minor's Name

First Name

Last Name

Minor's Date of Birth

YYYY

Minor's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Legal Guardian's Name Completing this Form

First Name

Last Name

Legal Guardian's Date of Birth

YYYY

Legal Guardian's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Legal Guardian's Email

Legal Guardian's Phone

(###)

###

####

Your Relationship to Minor

Describe Your Custody of Minor

Anything else...

SIGNATURE SECTION BELOW

Type Name as Signature

First Name

Last Name

Today's Date of Signing

YYYY

Consent To Treat Minor

*I agree and attest to the following: *I am the legal parent or custodian of the child-client. *I have a legal right to obtain care for the above-named child-client. *I understand that in instances of divorce, it is important that BOTH parents of the child grant permission for services. I authorize the mental health assessment and treatment of the above-named minor child. Authorization will be in effect until such time as this professional relationship is terminated, or until consent is revoked. As the legal custodial parent, I understand that I have the right to information concerning my minor child in therapy, except where otherwise stated by law. This is my written consent to the mental health assessment and care of my minor child under the terms stated above.