DBH Guardian Authorization

Intake Department

135 Webster St. Suite 1 Hanover, MA 02339 P. 781-429-7755 x1 F. 781-465-7995 E. intakes@danabehavioralhealth.org
Guardian Authorization for Treatment of a Child
I, parent/guardian name* , date of birth* , being the parent and/or legal guardian of child's name* date of birth*, hereinafter my child, do hereby authorize Dana Behavioral Health to provide Behavioral Health Care for my child.
Signature of parent and / or legal guardian*
Relationship to child*
Date signed*

MonthDayYear
Date
Should be Empty:

Intake Department