Minor/adolescent assent and parent/guardian agreement

The below assent form is found in the provider portal under the Resources tab in the Documents and Forms section.


Minor/Adolescent Assent

SUD Specialty Group – CA, Mental Health Specialty Group, P.A., and Mental Health Specialty Group NJ, PC (collectively, “Group”) working with its affiliates and its engaged clinicians (collectively, “Provider”) provides mental health and substance use disorder treatment. 


When you communicate with your Provider, we will discuss mental health and substance use concerns. Your provider will ask you questions, listen to you and suggest a plan for improvement. 


It is important that you feel comfortable talking with your Provider. For many people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their therapist. Privacy, also called confidentiality, is an important and necessary part of treatment.

Confidentiality cannot be maintained when:

  • You tell your Provider, or your Provider learns from others, that you plan to cause serious harm or death to yourself, and we believe you have the intent and ability to carry out this threat in the very near future. We must take steps to inform a parent or guardian of what you have shared and how serious we believe this threat to be. We must make sure that you are protected from harming yourself.
  • You tell your Provider, or your Provider learns from others, that you plan to cause serious harm or death to someone else who can be identified, and we believe you have the intent and ability to carry out this threat in the very near future. In this situation, we must inform your parent or guardian, and we must inform the person who you intend to harm. 
  • You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. Examples include, but are not limited to, self-harm that can cause serious damage, engaging in risky behaviors that can harm you or others, etc. In these situations, your Provider will use professional judgment to decide whether a parent or guardian should be informed.
  • You tell your Provider, or your Provider learns from others, that you are being abused-physically, sexually or emotionally-or that you have been abused in the past. In this situation, we are required by law to report the abuse.
  • Sometimes your Provider may need to work together with your doctor or another Provider. Your Provider will get written permission from your parent or guardian in advance before information with your doctor.


Except for situations such as those mentioned above or when required by law, we will not tell your parents or guardians specific details about what you share with us in your private therapy sessions. We will share general information with your parents or guardians so that they can support your experience in treatment. This may include information such as scheduling details, your treatment plan and general progress that you make.  


For minors in California, Texas, Ohio, New York, Virginia, Florida, and Georgia:

You should also know that, by law, your parent/guardian has the right to see any written records we keep about our sessions, unless your Provider determines that access to such records will be detrimental to your progress. We only put in the written record information that is relevant to your treatment.


For minors in North Carolina: 

North Carolina law allows minors as young as 12 to restrict parental access to medical records. 


For minors in Illinois: 

Under Illinois law, minors age 12 through 17 have the right to access and authorize release of their own mental health records and information, and their parents have such rights only if the minor does not object or the therapist does not feel there are compelling reasons to deny parental access. 


Please verbally acknowledge with your Provider that you understand the limits to confidentiality. If you have any questions as we progress, you can ask your Provider at any time.



Parent/Guardian:  You verbally acknowledge that this assent has been reviewed by you, your minor and the Provider. 


Please indicate your agreement to respect your adolescent or teen’s privacy:

  1. You will refrain from requesting detailed information about individual therapy sessions with your child. You understand that you will be provided with periodic updates about general progress, and/or may be asked to participate in parent therapy sessions as needed.
  2. You understand that you will be informed about situations that could endanger your child. You know the decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment.

Was this article helpful?

1 out of 1 found this helpful