Consent by Minor to Counseling


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

Phone 512-245-2208 ∙ Fax 512-245-2234 ∙



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




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

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