Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Answer each question until you see the instructions in red text Is the child 14 or older, emancipated, married, or a high school graduate?YesNoIs this an emergency?YesNoDoes the child give consentYesNoAre the parents married (even if separated) or were they ever married without a court order of joint custody?YesNoDoes the parent (or guardian) calling for the appointment have sole legal custody? (You may need to describe what sole legal custody means)YesNoIs there a court order for Treatment?YesNoCan the other parent be located?YesNoWill the other parent consent?YesNoAttempt to locate the other parent (e.g. Letter to last known address) any response?YesNoSchedule an appointment if clinically indicated Do not treat unless emergency Follow instructions of responding parent unless emergency Schedule appointment if clinically indicated and document efforts Reset
