RBH Consent for Treatment of a Minor

Date of Scheduled Intake: (Pls note all consent forms must be returned at least 48 hours prior to the patient's scheduled appointment)*

Date

Patient Name (Name of Child/Adolescent)*

First NameLast Name

Patient's DOB:*

Date

Please submit a photo of the child/adolescent:

Name of Person Completing this form? [NOTE: This Consent form must be completed by a biological parent who is a primary or joint managing conservator or legal guardian who has the legal authority to consent to treatment for a minor. Please note that other family members, aunts, uncles, grandparents, step-parents are not legally able to provide consent for treatment of a minor]*

Biological Parent or Legal Guardian only

Relation of person signing this form to Child/Adolescent Patient?*

Phone # for Parent or Legal Guardian completing this form:*

Area CodePhone Number

Email Address for Parent or Legal Guardian completing this form.*

Who is the child living with?*

Both Biological Parents - either together in one home or time spent living with each parent in separate homesOne Biological ParentAdoptive ParentsOther Legal Guardian

Pls select marital status of biological parents?

MarriedSeparatedDivorced {Please complete section below]Widowed

If Divorced, who is Managing Conservator for the child who has the legal authority per the divorce decree to consent for treatment of a child?

Have you provided RBH with a copy of the Divorce Decree?

YesNo [Pls send the full Divorce Decree as well as any other court documents pertaining to parental rights to consent for treatment of a minor to RBH via fax to (210) 745-4525 or via email to admin@rbh-sa.com at least 48 hours prior to the child's intake appointment.N/A

Has there been a court order designating a Legal Guardian or A Power of Attorney for Health Care Decisions?

Yes, pls list legal guardian name belowNo, one or both of biological parents are the child's legal guardiansN/A

What is the Reason for the Court Order designating a Legal Guardian, if applicable

Pls list the name and relation to the child for the Other Legal Guardian if applicable:

_________________________________________________________________________________________________

Texas law provides that, unless limited by a court order, a parent appointed as conservator (managing or possessory) of a minor has, at all times, the following rights:

a. The right of access to medical, dental, psychological, and educational records of a minor;

b. The right to consult with a physician, dentist, or psychologist of the minor;

c. The right to be designated on the minor’s records as a person to be notified in case of emergency; and,

d. The right to give consent for any emergency health care, including surgical procedures.

Sole or joint managing conservator parent(s) have all the rights listed above and may give consent for a minor’s non-emergency invasive surgical procedure and may consent to psychological or psychiatric treatment of a minor, unless limited by a court order.

Non-Parent Conservators a. Non-Parent Sole Managing Conservator: Non-parent sole managing conservators have the right to provide consent for the minor to receive medical, psychiatric, psychological, dental, and surgical treatment and to have access to the minor’s medical record.

A minor may provide consent for medical, dental, psychological and surgical treatment of the minor if the minor:

1. Is on active duty with the armed services of the United States of America;

2. Is 16 years of age or older and resides separate and apart from his or her parents, managing conservator, or guardian, and, is managing his or her own financial affairs,

3. Consents to examination and treatment for drug or chemical addiction, drug or chemical dependency, or any other condition directly related to drug or chemical use; or emergency psychiatric or psychological services

Philosophy of Care: RBH believes that children and minors suffer when the parents are not in agreement when it comes to making decisions about providing psychological evaluation and treatment services. RBH does not get involved in disputes between parents encourages cooperative involvement from both parents in the treatment planning for the minor. RBH believes that psychological treatment for a child should be offered to support the child’s optimal well-being and functioning. It is best for families to reach consensus on the goal of seeking evaluation or therapy services for their child or minor. Parents agree to provide the required documentation of conservatorship detailing parental rights and to refrain from utilizing the child’s treatment at RBH as part of any dispute between the parents.

My signature below certifies that the information conveyed herein is an accurate reflection of the court-ordered designations for conservatorship of the minor listed above. Note: The Managing Conservator/Custodial Parent must sign all consent forms for the evaluation and treatment of the minor.

My signature certifies that the information conveyed herein is an accurate reflection of the court-ordered designations for conservatorship of the minor listed above. Note: The Managing Conservator/Custodial Parent must sign all consent forms for the evaluation and treatment of the minor.

Date