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Consent for Treatment of Minor(s)

We/I, the undersigned parent(s), legal conservator(s), and/or guardian(s) of minor child(ren)

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hereby give full and unconditional authority for professionals with Pathways Forensic & Mental Health Services, PLLC to proceed with clinical evaluation and treatment of my/our minor child as their professional judgment indicates. This consent is given by me/us as parent(s) and/or guardian(s) of said child. We/I have legal authority to consent to medical, psychological, and mental health assessment and treatment of said minor child. It is clearly understood that you are hereby fully released from any claims and demands that might arise, or be incident to the evaluation and/or treatment, provided that professionals with Pathways Forensic & Mental Health Services, PLLC’s duties are performed with standard care and responsibility to the best of their professional ability.

This consent is given by me/us as parent(s) and/or guardian(s) of said child. We/I have legal authority to consent to medical, psychological, and mental health assessment and treatment of said minor child. It is clearly understood that you are hereby fully released from any claims and demands that might arise, or be incident to the evaluation and/or treatment, provided that professionals with Pathways Forensic & Mental Health Services, PLLC’s duties are performed with standard care and responsibility to the best of their professional ability.

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Pathways | Forensic & Mental Health | Lufkin & Nacogdoches

CLIENT INFORMATION (Person receiving services)

EMPLOYER INFORMATION

FAMILY INFORMATION

Children, Age, In Home

MEDICAL INFORMATION

MENTAL AND EMOTIONAL HEALTH

SUBSTANCE USE/ABUSE HISTORY

COURT-RELATED CLIENTS:

GENERAL CONSENT FOR USE OF ELECTRONIC MEDIA:

Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Consent for Treatment of Minor(s)

Main Office - Lufkin

Pathways Forensic & Mental Health Services, PLLC

103 Wildlife Lane
Lufkin, TX 75904

Newest Location - Nacogdoches

Pathways Forensic & Mental Health Services, PLLC

1132 NW Stallings Dr., Ste. 2
Nacogdoches, TX 75964