Authorization to Provide Treatment to Minor

Authorization to Provide Treatment to a Minor

Orchard Human Service, Inc. is a 501(c)3 nonprofit that provides direct services to children, adults, and families. Some of the services we provide include:

1. Educational, Behavioral, Developmental Intervention

2. Life Coaching Services and Support

3. Clinical Mental Health Counseling

4. Psychotherapy or Psychological Talk Therapy

5. Educational Therapy [non-clinical]

6. Non-Clinical Psychological Intervention and Consultation

7. Educational Intervention and Advocacy Services

8. IEP, EIP, Section 504 Advocacy and Consultation Services

I have legal custody of the minor child*

First NameLast Name

Whose Date of Birth is*

Date

With my signature below, I authorize the staff of Orchard Human Services, Inc. to provide counseling, psychotherapy, and intervention services to my child.

Additionally, I authorize the following individuals* to allow my child to receive services; and I agree that these individuals are authorized to be involved in the treatment and intervention plan, and have access to those records not protected by client confidentiality.

*Individuals who will bring child to counseling/therapy/intervention appointments

Individual 1

First NameLast Name

Relationship to Minor

Individual 2

First NameLast Name

Relationship to Minor

Individual 3

First NameLast Name

Relationship to Minor

By signing below, I provide permission and authorization for the care and treatment of my minor child as set forth in this document.

Signature of Individual or Legal Representative *

Name of Individual or Legal Representative *

First NameLast Name

Relationship to Minor*

Date*

Date

Please submit documentation by one of the following methods:

Email scanned copies or picture of document to Forms@OrchardHumanServices.org
Fax documents to (877)660-8884
Send for physical delivery by USPS or other service to: Orchard Human Services, Inc. | 231 Bentonville Ln | Douglasville GA 30134

Take a photo of Signer's Drivers License

Upload an image of the Signer's Drivers License

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Please also provide a copy of any documents pertaining to parenting plans, custody court orders, and which adult has the legal right to make decisions about healthcare for the minor child.

Upload parenting plans and/or custody court orders

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