Consent to Treat a Minor

For patients under 18 years of age. Under California law, psychiatric treatment of a minor requires the consent of all custodial parents or legal guardians. Please complete this form before the first appointment.

1 · Both-Parent Consent Requirement

Treatment of a minor by Dr. Gordon Wong MD, MPH ("the Practice") will only proceed with the consent of all custodial parents or legal guardians. Where a court order, custody decree, or other legal document modifies parental authority, the signing parent or guardian agrees to provide a copy of that document on request before treatment begins.

2 · How Consent Is Provided

The consent of every custodial parent or guardian may be provided in one of two ways:

Co-signature on this form — both parents may complete and sign the parent sections below; or
Written email consent — the absent parent may send a written, signed consent to gordon@gordonwongmd.com from their own email address before treatment begins.

Treatment will not begin until consent from every required parent/guardian has been received.

3 · Scope of Consent

I authorize Dr. Wong to evaluate the minor patient named below, to provide psychiatric care including diagnostic assessment and the prescription of medication where clinically indicated, and to coordinate care with other treating clinicians as necessary.

4 · Confidentiality

I understand that California law affords adolescent patients certain confidentiality rights with respect to mental-health treatment, and that Dr. Wong will discuss with me how clinical information will be shared between the patient, parents, and other parties as part of the treatment relationship.

5 · Financial Responsibility

I accept financial responsibility for all care provided to the minor patient under this consent, in accordance with the Practice's Financial Policy and Card-on-File Authorization signed separately.

6 · Electronic Signature

By typing my full legal name and clicking "Submit Consent," I am providing my electronic signature with the same legal force and effect as a handwritten signature, in accordance with the federal E-SIGN Act (15 U.S.C. §7001 et seq.) and the California Uniform Electronic Transactions Act (Cal. Civ. Code §1633.1 et seq.).

1 Minor Patient

First Name*

Last Name*

Date of Birth*

2 Custody Situation

Who has custodial authority for this minor?*

Both Parents (Married / Together)

Divorced — Joint / Partial Custody

Sole Custody

Legal Guardian

If sole custody or legal guardianship, please be prepared to provide documentation on request.

3 Parent / Legal Guardian #1 (Signing Now)

First Name*

Last Name*

Relationship*

Phone*

Email*

4 Parent / Legal Guardian #2

Choose how the second parent's consent will be provided:

Co-Sign Below

Email Consent Separately

I have read and understood the Consent to Treat a Minor above. I confirm that I have legal authority to consent to medical treatment for the minor named above, and I will provide documentation of any sole custody or guardianship on request. I consent to psychiatric evaluation and treatment of the minor by Dr. Wong as described in the form above.

✓ Parent / Guardian #1 Signature

Type Your Full Legal Name*

By typing your name, you are signing this consent electronically

Records of Signature Retained · gordonwongmd.com