Attachment 20a - Consent For Therapeutic Behavioral Services - Riverside County Department Of Mental Health

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Attachment 20A
Riverside County Department of Mental Health
Consent for Therapeutic Behavioral Services
(Revised 6/14/01)
I, the parent/legal guardian of ____________________________________
D.O.B.________________
do agree that Therapeutic Behavioral services (TBS) are needed for my child on a short-term basis to address
behaviors/symptoms which put him/her at risk of placement or hospitalization. I understand that I must work
closely with the clinician for my child and the TBS provider to make a plan for these services to be delivered to my
child. At any time, I can request a change in the service or termination of the service through a discussion with my
clinician and TBS provider.
I hereby give permission for the above mentioned minor to go on outings with ____________________________
(TBS Coach), and I also authorize any emergency treatment by proper medical authorities for any accident or illness while
in the care of the above mentioned TBS Coach. I also give permission for this form to be photocopied.
Parent/Care Provider’s Name (please print) ________________________________________________________
Relationship
Address/City
Day Phone: ___________________________ Evening Phone: ____________________________________
Family Doctor’s Name ______________________________________________________________________
Address/City ___________________________________________ Phone
Medical Insurance: _______________________ Member Number: ___________ Expiration Date: __________
PERSON(S) TO CONTACT IN CASE OF EMERGENCY, IF PARENT/ CARE PROVIDER NOT AT HOME
Name _________________________ Relationship _________________Phone
Address/City
Name _________________________ Relationship _________________Phone
Address/City
Signature of Parent or Guardian ____________________________________
Date _________________
Relationship to child:
Copy to:
Parent(s)
Clinician
TBS Worker
TBS Supervisor
A COPY OF THIS FORM IS AS GOOD AS THE ORIGINAL
Attachment 20A – TBS Consent for Services
Page 1 of 1
February 2012
Confidential Client Information, See W&I Code 5328

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