Confidential Handling of Health Information for Minors CONFIDENTIAL HANDLING OF HEALTH INFORMATION FOR MINORS * All reasonable requests to communicate with you and to convey health information, as well as billing information, using your preferred methods, will be accommodated. Please list and check ALL methods by which you approve and prefer for receiving your health and/or billing information. I/we are requesting confidential health information on behalf of the following minor: First Name Last Name Parent/Guardian 1 * First Name Last Name Home Phone (###) ### #### Cellular Phone (###) ### #### Okay to Text? Yes No Work Phone (###) ### #### Email Address * Send to the Following Address: Parent/Guardian 2 First Name Last Name Home Phone (###) ### #### Cellular Phone (###) ### #### Okay to Text? Yes No Work Phone (###) ### #### Email Address Send to the Following Address: Parent/Guardian 1 ELECTRONIC SIGNATURE AND CONSENT * I understand that there may be times when I may provide the therapist with additional means for communication, outside of those listed above. It will be understood that these too will be considered patient-authorized confidential communications. Below is my electronic signature. First Name Last Name Relationship to Patient * Date Signed * MM DD YYYY Parent/Guardian 2 ELECTRONIC SIGNATURE AND CONSENT I understand that there may be times when I may provide my therapist with additional means for communication, outside of those listed above. It will be understood that these too will be considered patient-authorized confidential communications. First Name Last Name Relationship to Patient Date Signed MM DD YYYY Thank you! Your form has been submitted.
