• Children's Advocacy Center
    Serving Bastrop, Lee & Fayette Counties
  • Authorization to Accompany Minor to Appointment

  • To Protect Your Child's Confidentiality

  • Please read this carefully.
  • Please list the name, relation, date of birth, and contact information for anyone authorized to:
  • 1. accompany your child to an appointment, and
    2. make medical decisions in your absence, and
    3. transport of a minor does not authorize access to protected health information; however, minimum necessary safety-related information may be disclosed to the adult present as required by HIPPA.
  • We will not be able to treat your child if accompanied by any person not listed below. (Please include YOURSELF, parents, step-parents, caregivers, grandparents, legal guardians, etc. that you grant authorization.
  • If you wish to change this information at any time - please notify our office in writing.
  • Date
     - -
  • Stacey Helm, LPC-S, LSOTP, NCC
    LPC-S #62725, LSOTP License #99836

  • Sarah Moreno, LPC, NCC-License #80546
    Franco Weaver, LPC, NCC-License #81843
    Brittney Sartor, LMSW-License #51814
  • Kelly Gilleland, PhD, LPC-S, LSOTP-S, NCC
    LPC-S License #72661, LSOTP-S License #99469
  • Matthew Robbins, LPC-License #93233
    Katie Gross, PhD, LPC-S-License #68505
  • Ashley Pattillo, LPC Associate-License #95503
    Supervised by Stacey Helm, LPC-S License #62725

  • Should be Empty: