Informed Consent to

Treat Minor Children

Last updated: August 21, 2025

This consent applies when a parent, legal guardian, or other legally authorized representative is providing consent for a minor to receive healthcare services from Neuroscience Psychiatry & Integrative Wellness PLLC (“Neuroscience Psychiatry”).

Nothing in this consent limits any right a minor may have under applicable law to consent independently to particular healthcare services.

Authority to Consent

By signing this consent, I represent that:

  • I am the minor patient's parent, legal guardian, or other person legally authorized to consent to the minor's healthcare; and

  • The information I provide regarding my authority to make healthcare decisions for the minor is accurate and complete.

I understand that Neuroscience Psychiatry may request documentation regarding legal custody, guardianship, medical decision-making authority, court orders, or other information necessary to determine who is authorized to consent to or participate in the minor's care.

I agree to notify Neuroscience Psychiatry promptly if my authority to make healthcare decisions for the minor changes.

Consent to Treatment

I authorize Neuroscience Psychiatry and its appropriately licensed healthcare professionals to evaluate and provide outpatient mental-health treatment to the minor as clinically appropriate.

Treatment may include:

  • Psychiatric assessment

  • Diagnosis

  • Medication management

  • Psychotherapy

  • Behavioral interventions

  • Patient and family education

  • Treatment planning

  • Monitoring

  • Coordination of care

Specific medications, procedures, or treatments may require additional discussion or consent.

No particular medication, treatment, diagnosis, or outcome is guaranteed.

Medication

I understand that medication may be considered when clinically appropriate.

Medication decisions are based on the clinician's professional judgment, the minor's individual clinical needs, applicable law, and available medical information.

No medication, including a controlled medication, is guaranteed solely because it is requested.

Additional evaluation, monitoring, records, laboratory testing, vital signs, treatment agreements, collateral information, or in-person assessment may be required when clinically appropriate.

Minor Participation and Assent

Neuroscience Psychiatry believes that involving minor patients appropriately in their own care can support effective treatment.

The clinician may explain treatment recommendations in a manner appropriate to the minor's age and developmental level and may seek the minor's agreement or assent when appropriate.

The clinician may also spend part of an appointment speaking privately with the minor when clinically appropriate.

Parent or Guardian Participation

Parent or guardian participation may be important to evaluation and treatment.

The extent of parent or guardian involvement may vary depending on:

  • The minor's age and developmental level

  • The type of treatment

  • Clinical needs

  • Safety considerations

  • Applicable law

  • The minor's legal ability to consent independently to particular services

The clinician will determine the clinically appropriate structure of appointments and parent or guardian participation consistent with applicable law.

Confidentiality and Access to Information

I understand that mental-health treatment works best when a minor can communicate openly with the clinician.

A parent or guardian may have rights to information concerning the minor's healthcare, but those rights are not necessarily unlimited in every circumstance.

Applicable law may permit a minor to consent independently to certain healthcare services and may provide additional confidentiality protections related to those services.

Neuroscience Psychiatry will manage access to the minor's health information according to applicable federal and state law.

The clinician may discuss appropriate confidentiality expectations with the minor and parent or guardian at the beginning of treatment.

Limits of Confidentiality

Confidentiality is not absolute.

Information may be disclosed when permitted or required by law, including circumstances involving:

  • A serious threat to the health or safety of the minor or another person

  • Suspected child abuse or neglect

  • Legally required reporting

  • Court orders or other legally authorized disclosures

  • Other circumstances permitted or required by applicable law

Telehealth

If the minor receives care by telehealth, I consent to the use of telehealth when clinically appropriate.

The minor may be asked to confirm their physical location at the time of an appointment.

The clinician may require a parent, guardian, or responsible adult to be available during or near a telehealth appointment when clinically appropriate.

The clinician may determine that an in-person evaluation or another level of care is necessary.

Emergencies

Neuroscience Psychiatry provides routine outpatient mental-health services and does not provide emergency or continuously monitored crisis services.

If the minor is experiencing a medical or psychiatric emergency:

Call 911 or go to the nearest emergency department.

For suicidal crisis or emotional distress:

Call or text 988.

Do not use routine email, text, voicemail, or portal messages for emergencies.

Communication

Routine communications may not be reviewed immediately.

The parent, guardian, responsible party, and minor patient are responsible for maintaining current contact information and monitoring communications relating to care.

Financial Responsibility and Insurance

When insurance information is provided and insurance billing is requested, I authorize Neuroscience Psychiatry to submit claims and provide information reasonably necessary for payment and healthcare operations as permitted by law.

I understand that insurance coverage and patient responsibility are determined by the health plan and applicable law.

Changes in Legal or Family Circumstances

I agree to notify Neuroscience Psychiatry promptly of:

  • Changes in legal custody

  • Changes in guardianship

  • Changes in medical decision-making authority

  • Court orders affecting healthcare decisions or access to records

  • Changes in insurance or responsible-party information

Neuroscience Psychiatry may pause non-emergency treatment when necessary to clarify legal authority to consent to care.

Changes in Legal or Family Circumstances

By signing, I acknowledge that:

  • I have read and understand this consent.

  • I have had an opportunity to ask questions.

  • I represent that I am legally authorized to provide consent for the minor when such consent is required.

  • I consent to outpatient mental-health treatment for the minor.

  • I consent to telehealth when clinically appropriate.

  • I understand that the minor may have independent rights regarding consent and confidentiality under applicable law.

  • I understand that treatment decisions remain subject to the clinician's professional judgment and applicable law.

Parent / Legal Guardian / Authorized Representative Name: ______________________

Relationship to Minor: ____________________________________________

Minor Patient Name: ____________________________________________

Signature: ____________________________________________

Date: ___________________________________________