I consent to my child’s participation in receiving a psychiatric consultation by mental health professionals at Washtenaw County Children’s Services for assessment and treatment recommendations.
- I understand that following the provision of any services, information will be provided concerning each of the following areas:
- The benefits and indications for any proposed treatment.
- The manner in which treatment will be administered
- Risks of side effects from medications (when applicable)
- Probable consequences of not receiving treatment
- Information from my child’s assessment and/or treatment will be stored in a confidential medical record at Washtenaw County Children’s Services, and I consent to disclosure for use by the parties I have indicated on the accompanying Consent to Share Behavioral Health Information Form for continuity of my child’s care. Information provided will be only be shared with the parties indicated on the Consent to Share Behavioral Health Information form, except for in the following instances:
- if youth is deemed to present a danger to himself/herself or others;
- if concerns about possible abuse or neglect arise; or
- if a court order is issued to obtain records.
- I have the right to withdraw my consent for evaluation and/or treatment of my child at any time by providing a written request to Washtenaw County Children’s Services.
- This consent will expire 12 months from the date of signature, unless otherwise specified.
I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation. I also attest that I am the legal guardian and have the right to consent for the treatment of this child. I understand that I have the right to ask questions of my child’s service provider about the above information at any time.