Informed Consent to Participate in Psychological Services and Special Limits of Confidentiality for Minors

Record #

Informed Consent to Participate in Psychological Services and Special Limits of Confidentiality for Minors

I(We) hereby authorize Angel Enrique Pacheco, Ph.D., C.Psych., his Assistants, and/or Associates to provide the professional services in psychology they may deem necessary while consulting, interviewing, assessing, and/or treating me, and/or the persons under my responsibility listed as follows:

             NAME                                 DATE OF BIRTH (dd-Mmm-yyyy)

I(We) provide the present authorization in my(our) condition of Parent – Tutor – Legal Representative (Circle One) of said minor(s).

I(We) understand that all information obtained in the course of these professional services will be maintained in strict confidence, and that this confidential information will only be divulged to me(us) when in the judgment of Dr. Pacheco, his Assistants, and/or Associates this is deemed to be appropriate or necessary.

IMPORTANT NOTICES:

If required, call Dr. Pacheco and, if not available immediately, please leave a voice mail message with your name, telephone number, and a brief description of the situation.  Your call will be answered as soon as possible.

In the event of an emergency, call 911, or go to the nearest Hospital Emergency Room, where you will be assisted.

ACCEPTED IN ACCORDANCE:

Printed Name                                                             Signature                                                             Date

________________________________________________________________________________________________

I(We),______________________________________________________________________________,

in my(our) condition of minor(s), hereby authorize Dr. Pacheco, his Assistants, and/or Associates to communicate, when considered appropriate or necessary, to my(our) parents, tutors, and/or legal representatives, any or all confidential information obtained during the course of these professional services.

IMPORTANT NOTICES:

If required, call Dr. Pacheco and, if not available immediately, please leave a voice mail message with your name, telephone number, and a brief description of the situation.  Your call will be answered as soon as possible.

In the event of an emergency, call 911, or go to the nearest Hospital Emergency Room, where you will be assisted.

ACCEPTED IN ACCORDANCE:

Printed Name                                                             Signature                                                             Date

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