Acknowledgement Form I, the undersigned, for a minor (under the legal age of 18), for whom I am the legal guardian, or for myself, hereby affirm that: I have read and fully understand Austin Mind and Behavioral Health Office policies, and I agree to abide by them. I have read the Notice of Privacy Practices on the website and know that I can request to receive an electronic or paper copy. Name of Patient or Minor* First Last Date of birth* Relation to person providing consent*I certify that I have read and fully understand the above statements and that I am providing this declaration voluntarily, without any coercion. ( Signature of Legal Guardian/Self )*Date* NameThis field is for validation purposes and should be left unchanged.
