Consent For Treatment Form (Minors With Divorced Or Separated Parents) in Austin, TX

Please read carefully this form as it contains important information regarding treatment of your child.

Please type your initials next to each statement after you read it.

Austin Mind and Behavioral Health or any of its providers, or affiliates are not responsible for ensuring that either of the parents follow legally binding divorce decree.*

Consent for treatment has to be provided by both parents, which can be in form of both parents present, or one parent is present and the other parent is contacted by phone during the appointment.*

Austin Mind and Behavioral Health or any of its providers, or affiliates cannot act as messenger between separated or divorced parents, and it is expected that parents will communicate with each other regarding care of the patient.*

I understand that Austin Mind and Behavioral Health or any of its providers, or affiliates do not provide legal testimony regarding custody of the child. I agree that I will not ask for clinician to provide testimony through subpoenas, legal summons, or in person testimony.*

With my initials above, I certify that I am the legal guardian of _____(TYPE CHILD'S FULL NAME BELOW)_____ and I understand and agree with the above statements.*

Name of legal guardian*

First Last

Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.