Consent for Treatment of a Minor

Thank you for Signing the Patient Complaint & Grievance Process

Step 4: Consent for Treatment of a Minor

Please continue by completing the consent for treatment of a minor.

By signing below, I/we agree to the practice policies of Sage Neuroscience Center (as laid out in Practice Policies) for the treatment of my minor child with the following additional items:

Information gained from sessions will be shared between patient (minor) and parent(s)/guardian(s) listed on this form only.

Each session may consist of time spent in part with patient only and in part with patient and parent(s)/guardian(s).

Information gained from session with patient-only that is not directly linked to emergencies, dangerousness to self or others, or crucial aspects of care given by parent(s)/guardian(s), will not be shared with parent(s)/guardian(s) without the patient’s consent (verbally or written).

Most psychiatric medications prescribed for minors have not been FDA approved for treatment (“off label use”) of minors due to ethical/logistic concerns of pharmaceutical manufacturers, but will be used based on consensus opinion of practicing psychiatrists working with children and adolescents.

Psychiatric medications prescribed will be approved by all parties involved: the doctor, the patient, and parent(s)/guardian(s).

By signing this form, I authorize Sage Neuroscience Center and its providers to recommend and prescribe treatment for my minor child. I understand that “off label use” of medications carries inherent risks and I have discussed these with the doctor. I also realize I retain the right to refuse medication at any time. I also acknowledge stopping medication carries inherent risks, and I will discuss this with the doctor before doing so.

Minor Name*

First Last

Minor Date of Birth*

Signature of Minor

1. Parent / Guardian Name*

First Last

Signature of Parent / Guardian 1*

2. Parent / Guardian Name

First Last

Signature of Parent / Guardian 2

CAPTCHA

Thank you for Signing the Patient Complaint & Grievance Process

Step 4: Consent for Treatment of a Minor

For more information about our services, contact us today at

Our mission is to provide comprehensive behavioral health and substance use treatment to the community. We empower individuals to achieve health, wellness and recovery.

The Expert: Sage Behavioral Health Blog