Minor Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

First Name

Last Name

Emergency Phone *

(###)

###

####

Services Offered *

I agree to the following services:

Counseling and therapy for mental health issues

Substance use counseling and treatment

PrEP (Pre-Exposure Prophylaxis) for HIV prevention

STI (Sexually Transmitted Infections) testing and treatment

Family planning services, contraception and pregnancy testing

Gender-affirming care (e.g., hormone therapy, counseling)

Confidential HIV testing and treatment

Name of Parent or Guardian *

First Name

Last Name

Understanding and Acknowledgment *

I understand that: These services are confidential, and my child’s healthcare provider will not disclose information to me without my child’s consent unless required by law. I have the right to ask questions about the services and to refuse any service I do not want for my child. By selecting yes below, I acknowledge that I have read and understand the above information and consent to my child receiving the selected health services.

Yes