Informed Consent for Activities (Minors)
Informed Consent for Activities (Minors)
Client Name: ______Date of Birth: ______
Parent/Legal Guardian: ______Phone Number: ______
As part of treatment at Southwest Behavioral Health Center (SBHC), yourchild may be involved in various social and physical activities and excursions from SBHC premises. These activities include, but are not limited to:
PLEASE INITIAL FOR ACKNOWLEDGMENT AND APPROVAL, WHERE INDICATED:
______I acknowledge that there may be risks associated with such activities and approve my child’s participation in such (initials) activities.
______I understand that in case of emergency involving my child, every effort will be made to contact me. If I cannot be (initials) contacted, SBHC may contact the names listed below:
Emergency Contacts:
Name: ______
Relationship to client:______
Phone #: ______
Name: ______
Relationship to client:______
Phone #: ______
______In the event that those persons (above) cannot be reached, SBHC staff may obtain proper treatment, including, (initials) but not limited to hospitalization, anesthesia, surgery, or injections ofmedication for my child.
_____I approve SBHCsharing the information with professionals who need to know in order to address my child’s
initials)emergency medicalneeds.
_____I agree to inform SBHC staff of any disabilities or medical conditions which may prevent or limit my child’s safe
(initials)participation in activities. Current disabilities or medical conditions include:
______My child hasno physical disabilities or medical conditions, that would prevent them from safelyparticipating in
(initials)the above activities.
_____My child indicates that they agree to abide by the rules and directions given to them by the SBHC staff before (initials) and during activities.
You and your child are aware that if your child does not abide by rules and directions, theymay lose the privilege of participation in SBHC activities.
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EMERGENCY MEDICAL INFORMATION
______My child has been treated for the following Allergies or Reactions to:
(initials)
- Medication______
- Food, Plants, or Insect Bites______
- Other______
______My child has no allergies or medication reactions
(initials)
MEDICATIONS
______My child is currently taking the following medications. (Copy this page if additional space is needed.) Please(initials) include Inhalers and EpiPen information, even if they are for occasional or emergency use only.
.
Medication______
Strength/dose______Frequency ______
Approximate date started: ______
Reason for medication______
Medication______
Strength/dose______Frequency ______
Approximate date started: ______
Reason for medication______
Medication______
Strength/dose______Frequency ______
Approximate date started: ______
Reason for medication______
Medication______
Strength/dose______Frequency ______
Approximate date started: ______
Reason for medication______
_____Qualified SBHC staff may give over the counter medications listed below. I understand that these medications will
(initials) only be given if my child expresses a need for medication (such as a headache, stomachache, etc.)
Approved Over-the-Counter Medications:
- ______
- ______
- ______
_____Do not give my child any Over-the-Counter medications.
(initials)
Signatures:
______
Parent or Legal GuardianDate
______
WitnessDate
This information has been disclosed to you from records protected by Federal confidentiality rules (42CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42CFR part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patients.
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Informed Consent for Activities (Minors) – MC –12-10