Form Dss-1812 - General Authorization For Treatment And Medication - North Carolina Department Of Health And Human Services
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2North Carolina Department of Health and Human Services │ Division of Social Services
General Authorization for Treatment and Medication
Section A – Identifying Information
Child’s Name:
Date of Birth:
Medical Home Provider:
Telephone Number:
Other Medical, Dental, or Mental Health Provider or Specialist
Telephone Number:
Prescribing or Administering Treatment:
Section B – Care, Treatment, and Parental Consent (N.C.G.S. § 7B-505.1)
When a child is in the custody of the county child welfare agency, the county director may arrange for, provide, or
consent to any of the following without obtaining parental consent:
Routine medical or dental care or treatment (including immunizations in most cases);
Emergency medical, surgical, psychiatric, psychological, or mental health care or treatment; and,
Testing and evaluation in exigent circumstances
I hereby authorize ____________________ county child welfare agency to consent to the following treatment of the
child identified above (include description):
Prescriptions for psychotropic medication(s): ________________________________________________
_______________________________________________________________________________________
Participation in a clinical trial: ____________________________________________________________
_______________________________________________________________________________________
Child Medical Evaluation not otherwise authorized (DSS-5143 Consent/Authorization for Child
Medical/Child/Family Evaluation must also be completed): ________________________________________
_______________________________________________________________________________________
Comprehensive clinical assessment, or other mental health evaluation(s): _________________________
_______________________________________________________________________________________
Surgical, medical, or dental procedure or test that requires informed consent: ______________________
_______________________________________________________________________________________
Psychiatric, psychological, or mental health care or treatment that requires informed consent: __________
_______________________________________________________________________________________
Other non-routine or non-emergency treatment or procedure: ____________________________________
_______________________________________________________________________________________
DSS-1812 (Created 02/2016)
Child Welfare Services
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