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It is the policy of Mindtra Health, LLC ("Mindtra") to obtain informed consent from a parent or legal guardian before providing telehealth mental health services to individuals under the age of 18 (the "minor") through licensed therapists or psychiatric providers (the "Providers") affiliated with Mindtra.
By proceeding, you represent and warrant that you understand and agree to the following terms:
You attest that you are the lawful parent or legal guardian of the minor and are authorized under state and federal law to consent to healthcare services on their behalf.
You consent to allow Providers affiliated with Mindtra to render mental health services to the minor, which may include therapy and/or medication management. You understand that such treatment will be based on the clinical judgment of the Provider and the specific treatment plan for which the minor is registered. Controlled substances may be prescribed only at the Provider's discretion in accordance with state and federal regulations. Some controlled substances may require an in-person evaluation before being prescribed, and monthly follow-ups may be necessary.
In addition to this consent, you acknowledge having reviewed and agreed to Mindtra's Terms of Use, Privacy Policy, and Informed Consent for Treatment. You understand that you may revoke this consent at any time by submitting written notice to info@mindtrahealth.com.
You acknowledge that while you are encouraged to attend the minor's initial consultation, participation in subsequent appointments is not guaranteed and is determined by the Provider based on what is clinically appropriate and in the best interest of the minor. Once the minor reaches the age of majority under applicable law, they may independently revoke your access to their care and records.
Until the minor reaches the age of majority, you will retain legal authority over their protected health information (PHI), including rights of access, disclosure, and decision-making as permitted by law. Information about how the minor's health records are protected and used is available in Mindtra's Notice of Privacy Practices.
You acknowledge that Providers must comply with mandatory reporting laws. This means that if a Provider reasonably believes the minor may pose a danger to themselves or others, or suspects abuse or neglect, the Provider may disclose relevant information to appropriate authorities or emergency responders.
You acknowledge that Mindtra and its Providers are not equipped to manage psychiatric or medical emergencies. In the event of a crisis or emergency, you agree to call 911 or proceed to the nearest emergency department.
When the minor reaches the age of majority, your participation in their care will end unless otherwise authorized by the individual. However, your payment method and/or insurance information may remain on file unless changed or canceled. As a result, you may continue to receive billing communications related to the individual's care.
By providing this consent, you affirm that you have the legal authority to do so, that you understand the nature and limitations of the services provided, and that you accept all the terms outlined above.
If you have any questions regarding this consent or services offered to minors, please contact us at:
📧 info@mindtrahealth.com
📍 Mindtra Health, LLC
44 NW 17th St, Homestead, FL 33030