Request For Services By A Minor FOR BERNALILLO, SANDOVAL & VALENCIA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant. Request For Services By A Minor ID # CLIENT FIRST NAME* CLIENT LAST NAME* CLIENT DOB* MM slash DD slash YYYY EMAIL* CLIENT PHONE*ALTERNATE PHONEDate* MM slash DD slash YYYY THIS FORM IS TO BE USED ONLY WHEN A CHILD 14 YEARS OF AGE OR OLDER IS REQUESTING SERVICES ON THEIR OWN BEHALF. I certify that I am 14 years of age or older and am requesting mental health services for myself from Southwest Family Guidance Center & Institute (SWFGC). By signing below, I acknowledge that SWFGC has advised me of the desirability of involving my parent/guardian/family in my treatment. I have decided that (initial selections below):PLEASE SELECT* I WOULD LIKE TO INVOLVE MY PARENT/GUARDIAN/FAMILY IN MY TREATMENT, IF POSSIBLE. I WOULD LIKE MY PARENT/GUARDIAN TO BE ADVISED THAT I AM RECEIVING SERVICES FROM SWFGC, BUT I DO NOT WANT THEM TO BE INVOLVED IN THOSE SERVICES. I DO NOT WANT MY PARENT/GUARDIAN TO BE ADVISED THAT I AM RECEIVING SERVICES FROM SWFGC. PLEASE CHECK* I UNDERSTAND THAT I ALWAYS HAVE THE OPTION TO INVOLVE MY PARENT/GUARDIAN/FAMILY IN SERVICES. DATE MM slash DD slash YYYY Regardless of the option(s) selected above, I understand that no one (including my parent/guardian) will receive information about my treatment without my express consent except to report suspected abuse or neglect, in cases of imminent threat of suicide, homicide, harm to myself, or harm to others, or as otherwise provided by law. In the case of a medical emergency, suspected abuse or neglect, or an imminent threat of suicide, homicide, harm to myself, or harm to others, I agree that SWFGC may contact the following (must be a person 18 or over):
