Healthcare Adolescent Packet

Healthcare Adolescent Packet

This packet collects clinical, administrative, and consent information for provision of medical and behavioral health services to adolescents. Information furnished herein will be maintained in the medical record and used for treatment, billing, and as otherwise permitted by law. Complete all applicable sections and sign the certification at the end of this packet.

Patient Information

Female Male Non-binary Other:

Emergency Contact

Parent / Guardian Information (if applicable)

Insurance Information

Medical History

Immunizations

Immunization status is requested to ensure safe provision of care. If available, bring immunization records to your visit.

Yes No If no, note which are missing:

Permissions & Consent

By checking the boxes below and signing this document, the undersigned grants the clinical team permission to provide the indicated services to the adolescent named above. These consents are voluntary and may be revoked in writing, except where services have already been provided in reliance on this consent. Certain services such as those required by law to be reported (e.g., abuse, imminent harm) are not subject to confidentiality.

I consent to routine medical evaluation and treatment, including physical exam and diagnostic tests, as deemed necessary by clinical staff.

I consent to behavioral health assessment and treatment (counseling, psychotherapy) as indicated.

I request confidential services where permitted by law (e.g., contraception, substance use counseling) and understand limits to confidentiality.

I authorize clinical staff to administer prescribed and standard over‑the‑counter medications as clinically appropriate.

If urgent treatment is required and I cannot be reached, I authorize emergency medical care to be provided, including transport to an appropriate facility.

Behavioral Health Screening

Please indicate if any of the following apply to the adolescent currently or within the past month.

Frequent sadness or depressed mood

Excessive worry or anxiety

Substance use concerns

Thoughts of self-harm or harming others

Release of Medical Information & HIPAA Acknowledgment

I acknowledge receipt of the facility's privacy practices and understand that my health information will be used for treatment, payment, and healthcare operations as allowed by law. I authorize disclosure of the adolescent's protected health information to the persons identified below or as necessary for care coordination and billing.

I authorize release of clinic records to the above-named individuals or to other providers as needed for continuity of care.

Certification & Acknowledgment

By signing below, I certify that the information in this packet is accurate to the best of my knowledge. I understand the nature of the services requested, the risks and benefits involved, and my right to withdraw consent in writing, except where care has already been provided. I understand mandatory reporting requirements for abuse, neglect, or imminent risk, and that limits to confidentiality may apply when safety concerns exist.

I grant permission for the adolescent named on this form to receive the indicated services. If signing on behalf of the adolescent as a parent or legal guardian, indicate relationship in the signature block.

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