Consent by Minor to Counseling

TEXAS STATE COUNSELING CENTER

Texas State University, LBJSC 5-4.1, 601 University Drive, San Marcos, TX 78666

Phone 512-245-2208 ∙ Fax 512-245-2234 ∙www.counseling.txst.edu

CONSENT FOR COUNSELING OF A MINOR

If you are a student under the age of 18, you may consent to mental health treatment in accordance with Texas Family Code Section 32.003 if one of the following applies to you:

(Initial all that apply)

    ____ I am now or have previously been married.

    ____ A court order has been entered legally removing the disabilities of my minority.

    ____ I am on active duty with the armed services of the United States of America.

    ____ I am 16 years of age or older and I reside separate and apart from my parents/managing   conservator/guardian and manage my own financial affairs.

    ____ I am seeking counseling for suicidal thoughts; substance abuse or dependency; or sexual, physical, or emotional abuse.

If none of these sections apply to you, a parent/guardian will need to provide consent by filling out the bottom of this form and submitting it to the Counseling Center prior to your first counseling appointment. 

I___________________(student) am requesting counseling from the Texas State University Counseling Center and understand that my parents/legal guardians have access to my Counseling/Mental Health Records and may speak with the Counseling Center about my mental health treatment.  By signing below, I certify that the information I have provided is accurate and that I have read and understand the content of this document, including the limits of confidentiality stated above.

_____________________________________                     ______________________         _____________________

Signature                                                                                             Student ID                                           Date

PARENT OR GUARDIAN

I___________________(parent/guardian) provide consent for ___________________(student) to receive counseling at the Texas State Counseling Center.  By signing this form, I certify that:

• I have read and understood the contents of this document

• I understand that I have access to Counseling/Mental Health Records and may speak with the Counseling Center about my student’s mental health treatment, if desired

• I understand that the content of counseling sessions is confidential and have read and understand exceptions to confidentiality outlined on the Counseling Center website at https://www.counseling.txst.edu/services/counsel/confidentiality.html

• I have read the Counseling Center’s Scope of Practice found at

https://www.counseling.txst.edu/about/scope-of-practice.html and understand that treatment may include referrals to other mental health or medical providers, as deemed necessary by Counseling Center staff

________________________________________________          ___________________________________

Parent/Guardian Signature                                                                          Date