Authorization of treatment of a Minor 0-10 Today's Date MM slash DD slash YYYY Email Location in which you would like your services? Grand Rapids Hibbing Aitkin International Falls Minor Child's Name: First Middle Last Date of Birth MM slash DD slash YYYY Authorization I authorize NORTHLAND COUNSELING CENTER and its staff to administer services and/or treatment to my child. I authorize NORTHLAND COUNSELING CENTER and its staff to administer services and/or treatment to my ward. What type of custody do you retain? Full Legal Custody Joint Legal Custody Physicaly Custody Other please specify below If other, or None, give name, address and phone of person with custodyResponsible Party Name First Last Responsible Party Name First Last Primary Contact Person's Email Consent to Treat Minor By checking this box you are giving consent to treat your minor child. You are acknowledging all information is true and correct.If you have a custody agreement please upload the documentation or fax or email it (fax and email provided at top of page):Max. file size: 300 MB.Please provide documentation of Custody ArrangementsSignature
