Authorization to Accompany Minor to Appointment

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.
Initial
Patient Name:
Patient DOB:
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.
Name
DOB
Relation
Contact #
Name
DOB
Relation
Contact #
Name
DOB
Relation
Contact #
Name
DOB
Relation
Contact #
If you wish to change this information at any time – please notify our office in writing.
Parent/Legal Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Stacey Helm, LPC-S, LSOTP, NCC LPC-S #62725, LSOTP License #99836

Franco Weaver, LPC, NCC – License #81843

Brittney Sartor, LMSW – License #51814

Sarah Moreno, LPC, NCC – License #80546
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: