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