Hope419

Email *

First and Last Name of Child *

Date of Birth of Child *

I GIVE MY PERMISSION FOR MY CHILD TO ATTEND APPOINTMENTS WITH THE NAMED ADULT BELOW IN MY ABSENCE

I also agree to be available by phone if possible during the appointment in case my child's provider has questions or needs to make changes to medications or treatment.

*If I am not available by phone I understand no changes to treatment can occur until I give my permission.

First and Last Name of person permitted to bring my child to appointments at Hope419 *

Relationship to Child *

Step-Parent

Grandparent or Other Relative

Family Friend

By signing and dating below, I, the parent or legal guardian, certify that I have the legal authority to authorize treatment for this child and authorize the individual named above to accompany my child to appointments at Hope419, whether in person or virtually, in my absence.

This form may also be used when custody or parenting documentation is unavailable or cannot be provided to Hope419. In those situations, this authorization serves to document that the child's parent(s) or legal guardian(s) are aware of and consent to the child receiving behavioral health services at Hope419 and that the individual named above is authorized to accompany the child to appointments. This authorization does not establish or modify legal custody, parental rights, or any court-ordered decision-making authority.

If there is a shared parenting plan or another individual with legal authority to consent to treatment, that individual must also complete and sign a separate "Permission to Obtain Treatment" form unless a court order specifically grants one parent sole authority to make healthcare decisions. By signing below, I certify that the information provided is true and accurate to the best of my knowledge.

By signing I certify that, to the best of my knowledge, all individuals with legal authority to consent to this child's behavioral healthcare have been informed of and agree with this authorization, unless a court order grants me sole authority to make healthcare decisions.

E-Signature *

Printed Name of Parent or Guardian *