Guardian Authorization Form for treatment of a child

Intakes Department
Phone. 781-429-7755 x 1 Fax. 781-465-7995 intakes@dana-group.org
Guardian Authorization

for treatment of a child
Guardian Authorization for Treatment of a Child

I, GUARDIAN NAME, GAURDIAN DOB, being the parent and / or legal guardian of CHILD NAME, CHILD DOB, hereinafter my child, do hereby authorize Dana Group Associates to provide Behavioral Health Care for my child.

Signature of parent and / or legal guardian

Relationship to child

Date signed
Guardian name *
Guardian (DOB) *
Child client name *
Child client DOB *
Signature of parent and / or legal guardian *

Clear
Guardian relationship to child client *
(e.g., mother, father, etc.)
Date signed *

Month Day Year
Date
Please verify that you are human *
Should be Empty: