Consent for Treatment Agreement for a Minor Patient

I am the legal guardian/parent of the minor patient. I hereby acknowledge and consent to the following terms and conditions regarding the medical care and treatment of the aforementioned minor patient at Haelan Psychiatry & Wellness.

1. Presence of Guardian/Parent:
I understand and agree that the minor patient will not be seen or treated without the presence of a legally authorized guardian or parent during medical appointments or procedures.

2. Legal Proof of Guardianship:
If the minor patient is accompanied by a legal guardian rather than a parent, Haelan Psychiatry & Wellness requires the presentation of legal proof of guardianship. Acceptable proof may include legal documentation such as court-issued guardianship papers or notarized letters of guardianship. I understand that the parent or legal guardian may be required to provide proof of identification.

3. Emergency Situation:
In the case of a medical or psychiatric emergency where immediate treatment is required, I authorize medical professionals at Haelan Psychiatry & Wellness to administer care to the minor patient or call 911.

4. Communication:
I authorize the clinic and medical staff at Haelan Psychiatry & Wellness to communicate with me regarding the minor patient’s condition, treatment plan, and related matters.

5. Release of Information:
I consent to the release of medical information related to the minor patient to authorized healthcare providers involved in the minor patient’s care.

6. Appointment Cancellation:
I understand that if the designated adult listed on any of the minor patient’s paperwork is not present physically, by phone, or through video communication at the scheduled appointment, the appointment will be considered a Haelan Psychiatry & Wellness No-Show occurrence with an associated $50 No-Show fee. The minor patient will not be seen for the appointment that day and will need to be rescheduled. I understand that it is my responsibility to notify Haelan Psychiatry & Wellness in advance.

7. In-office Follow-Up:
If a follow-up appointment is scheduled, I acknowledge that it may need to be conducted in person/in-office, and the presence of the parent or guardian is required for in-person follow-up appointments. I understand that the parent or legal guardian may be asked to present a form of identification.

8. Responsibilities:
I acknowledge that it is my responsibility to provide accurate and up-to-date medical history and information about the minor patient.

9. Termination of Consent:
This consent agreement shall remain valid until revoked in writing by the undersigned legal guardian or parent.

Submitting Proof of Guardianship is required for all minor patients. Failure to submit documentation will result in cancellation of the minor patient’s current or upcoming appointment(s).