Legal Minor Intake Package

LEGAL MINOR INTAKE PACKAGE

This Legal Minor Intake Package (the "Agreement") is made and entered into as of Effective Date: by and between Guardian Name: (hereinafter "Guardian"), on behalf of Minor Name: (the "Minor"), and Provider Name: (hereinafter "Provider").

RECITALS

WHEREAS, Guardian is the lawful parent or legal guardian of the Minor and has authority to consent to services, representation, and release of records on behalf of the Minor; and

WHEREAS, Guardian has requested that Provider perform intake, assessment, and related professional services for the Minor and to obtain necessary medical, educational, and other records as required to provide such services; and

WHEREAS, the parties desire to set forth the consent, authorizations, disclosures, and administrative information necessary to commence services for the Minor.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. IDENTIFYING INFORMATION

2. GUARDIAN AND CONTACT INFORMATION

3. MEDICAL, INSURANCE AND ALLERGIES

4. REASON FOR REFERRAL AND HISTORY

5. AUTHORIZATIONS AND CONSENTS

Guardian hereby expressly authorizes Provider to assess and to provide services for the Minor, which may include intake assessment, therapeutic intervention, case management, and coordination with third-party service providers and educational personnel as reasonably necessary to further the Minor's care. Guardian affirms that Guardian has the legal authority to provide this consent.

Release scope: Provider is authorized to request and receive the Minor's medical, psychological, educational, and institutional records relevant to the provision of services. This authorization remains effective for the duration of engagement unless revoked in writing.

I consent to release of records as described above.

I authorize emergency medical care if needed during Provider activities.

6. CONFIDENTIALITY; REPORTING REQUIREMENTS

All communications and records created in the provision of services are confidential and will not be disclosed except as authorized by this Agreement or as required by law. Provider will comply with mandatory reporting obligations for suspected child abuse, neglect, threats of harm to self or others, or other statutory reporting duties. Guardian acknowledges these exceptions and consents to necessary disclosures to comply with such legal obligations.

7. FEES, BILLING, AND PAYMENT RESPONSIBILITY

Provider's professional fees, billing practices, and terms for payment are set forth below. Guardian is responsible for payment of all fees for services provided to the Minor unless otherwise agreed in a separate written fee agreement signed by both parties.

Guardian agrees to notify Provider promptly of any changes in insurance or responsible parties. Guardian remains ultimately responsible for charges not covered or paid by insurance or third parties.

8. RECORDS RETENTION AND STORAGE

Provider shall maintain records in accordance with applicable professional standards and law. Guardian may request copies of records, subject to reasonable fees for duplication and any legal restrictions concerning minors' records. Provider may retain electronic copies consistent with privacy obligations.

9. TERMINATION

Either party may terminate services upon written notice. Termination does not relieve Guardian of payment obligations for services performed prior to termination. Provider may terminate for nonpayment or conduct that jeopardizes safety or provision of services.

10. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses below by hand delivery, certified mail, or other verifiable means. Notice is effective upon receipt.

11. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Agreement shall be governed by and construed in accordance with the laws of the state chosen by the Provider in its standard operating procedures, without regard to conflicts of law principles. If any provision of this Agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Agreement, together with any separate, signed fee agreement, constitutes the entire agreement of the parties relating to the subject matter herein and supersedes all prior discussions and agreements.

12. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment to this Agreement must be in writing and signed by both parties. Failure to enforce any provision is not a waiver of future enforcement. This Agreement may be executed in counterparts and by electronic signature, each of which shall be deemed an original.

13. CERTIFICATION BY GUARDIAN

By signing below, Guardian certifies that Guardian is the parent or legal guardian of the Minor, that all information provided in this Intake Package is true and accurate to the best of Guardian's knowledge, and that Guardian has the authority to consent to services and records release on behalf of the Minor.

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