PARENTAL CONSENT FOR MENTAL HEALTH TREATMENT OF A MINOR
As the parent or legal guardian with the authority to consent on behalf of the minor child named above, I hereby consent for the minor to seek counseling, psychotherapy, psychological assessment and/or psychiatric care from the professional staff associated with or employed by PlushCare, Inc. (“PlushCare”). I represent and warrant that I am authorized to grant this consent on behalf of myself and any other parent or legal guardian required to consent in order for the minor to receive the care described herein.
The mental health provider responsible for the care, PlushCare(1), has explained to me the proposed treatment plan, the general nature and extent of any risks involved in the treatment, and alternative treatment options, if any. This consent will be valid until the minor reaches the age of majority, but can be revoked at any time by written notification from the parent of guardian.
Any questions relating to this form or the proposed treatment can be directed to PlushCare at [email protected].
1Consisting of the following medical practices:
PlushCare of California, Inc., PC
PlushCare Physician's Group Ltd.
PlushCare Physician's Group of Wyoming, Inc., PC
PlushCare Physician's Group, PC.