Guardian Authorization Form for treatment of a child

Intakes Department

135 Webster St. Suite 1 Hanover, MA 02339 P. 781-429-7755 x1 F. 781-465-7995
Guardian Authorization for Treatment of a child
I, *
Name of Parent/Legal Guardian
DOB *
DOB of Parent/Legal Guardian
,being the parent and / or legal guardian of
Child client name *
Child client DOB *
hereinafter my child, do hereby authorize Dana Group Associates to provide Behavioral Health Care for my child.
LEGIBLE Signature of parent /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:

Guardian Authorization for Treatment of a child