Consent to Evaluate and Treat a Minor

I client's parent name*, as the parent/legal guardian ofminor's legal name*. DOB Date* consent for the evaluation and treatment of this minor and I hereby certify that I have the legal right to seek counseling treatment for minor(s) in my custody and give permission to Boundless Hope* to provide treatment to my minor child(ren).
*Boundless Hope is defined as any and all Boundless Hope clinical staff, whether 1099 contracted or W2 staff.

Please select which of the following applies to your child:*

There is a parenting or custody order in place for the clientThere is NOT a parenting or custody order of any kind in place for the client

Please answer the following in regard to the parenting/custody order:*

I DO have the right to seek treatment for my child (the client) without the second parent/guardian's consentI DO NOT have the right to seek treatment for my child (the client) without the other parent/guardian's consent

Please select which of the following applies to your child:*

There is another parent/legal guardian in the client’s lifeThere is NOT another parent/legal guardian in the client's life

The minor's other parent/legal guardian who will be consenting to treatment is First Name* Last Name* . They can be reached at Phone Number or Email* .

By submitting this form and signing below I attest that all of my answers are true. I also attest that if I have any existing documentation, whether a temporary or permanent order, it has been uploaded below.

If I fail to upload existing documentation and am found in violation of an existing legal order, I release Boundless Hope LLC from any and all legal responsibility related to the provision of care for the minor listed above.

Knowingly withholding accurate legal parenting orders will likely result in termination of care. Referrals will be available upon request.

Decision Making/ Parenting Order Upload*

Only applicable for separated/divorced parents. If this does not apply, you may upload a photo of your driver's license or a blank pdf.

Consent for the evaluation and treatment of this minor:

By voluntarily signing below, I understand that my child, although a minor, is legally and ethically given total confidentiality with the exception being those circumstances discussed on consent to treatment form which are danger to self, danger to others, or being endangered by others. I am also giving Boundless Hope consent to contact the Department of Children and Family Services (DCF) as needed.

Parent/Legal Guardian Signature*

Relation To Minor*

Date*

Date

If treatment is for a non driving minor, it is REQUIRED that the designated responsible adult, remain on site at Boundless Hope for the duration of treatment. If I permit anther adult to transport my child, their name and relationship to minor is listed below.

Transportation to and from given to: (Name and relationship to minor)*

Parent/Guardian Valid Government Issued ID*

Email for a copy of form to your inbox!*

example@example.com

Are you involved in a high-conflict separation/divorce?*

Please explain.*

Do you have an open case with DCF?*

If yes, fill below. If no, type "n/a" in the blanks.
The case number is Case #* . The case worker's name is Caseworker Name* and their contact information is Email/Phone Number*