Informed Consent to Treat Minor Children

Last modified March 18, 2024

It is the general policy of Brightside Health to obtain the informed consent of a parent or legal guardian prior to permitting minors (in most states, individuals under the age of 18) to access the telehealth services (‘the Services”) provided by licensed therapists and clinicians affiliated with Brightside Health and/or the Brightside Medical professional corporations (“Provider(s)”).

By proceeding, you acknowledge that you understand and agree with the following and that the following representations are true.

1. I attest that I am the rightful parent or guardian of this minor and am legally empowered to consent to the provision of healthcare services for the minor.
2. I give consent for Brightside affiliated Providers to provide mental health care to the minor, which may include medication and/or therapy, based on the treatment plan(s) I register the minor for and as long as such treatment is deemed clinically appropriate by the minor’s Provider(s). I understand that under no circumstances shall a Brightside affiliated Provider prescribe a controlled substance to the minor, and that I should not register the minor for Services if my expectation is for the minor to be prescribed a controlled substance. In addition to this consent, I have read and consented to the Brightside Health Terms of Use and Telehealth Consent. I understand I can revoke this consent at any time by emailing [email protected].
3. I may have certain rights related to my participation in the minor’s care. I understand that I am invited to attend the minor’s initial consultation with a Provider, but may or may not be invited to participate in subsequent consultations based on what the Provider(s) deem is in the best interest in optimizing the Services provided to the minor. I understand that when the minor reaches the age of majority, they may unilaterally revoke my right to participate in their care.
4. I understand and the minor consents that, in accordance with terms and administrative protocols of Brightside’s Teen Care program, I shall maintain primary custody over the minor’s protected health information until the minor reaches the age of majority. This shall include, but not be limited to, the ability to access, disclose, and make decisions regarding my child’s medical records and related health information. A comprehensive explanation of how the minor’s medical records may be used or disclosed can be found in Brightside’s Notice of Privacy Practices.
5. I realize that the Information related to my child’s treatment will remain confidential in line with all applicable laws and regulations, but that certain circumstances may require the Provider(s) to disclose certain information to third parties such as emergency service personnel, or legal authorities. Such disclosures may occur if a Provider determines that the minor poses a serious threat of harm or death to themselves or another person, or a Provider believes that the minor has been in some way neglected or abused.
6. Providers are not equipped to handle psychiatric or medical emergencies and that I will call 911 or go to the nearest emergency room if such a situation arises.
7. I understand that I will no longer be involved in the teen’s care when they reach the age of majority; however, their plan will not be canceled and the form of payment and/or insurance will remain the same unless either party cancels payment or the teen updates their payment information. Consequently, I may continue to receive financial information from Brightside or my insurance provider pertaining to the teen’s care.

I am authorized to consent on minor’s behalf and acknowledge and agree to all terms listed above.