Informed Consent for Minors
Informed Consent
Last Updated: November 2, 2026
Last Updated: August 12, 2024
This Minor Enrollment and Consent to Care (“Consent”) is made by the undersigned individual who has not attained the age of majority under the laws of the state in which the individual is located when receiving the Services (generally eighteen (18) years of age, and nineteen (19) or twenty-one (21) in certain states) (the “Minor”), in connection with the Minor’s enrollment for mental-health treatment services, including therapy and medication management services (collectively, the “Services”), furnished by Blossom BH Opco, Inc. (“Blossom”). An individual who is emancipated, or who is otherwise entitled under applicable law to consent to the Services as an adult, should not use this Consent and should instead acknowledge Blossom’s standard Informed Consent. Capitalized terms have the meanings given herein.
1. Eligibility; Condition Precedent to Services
The Minor acknowledges that the Minor has not attained the age of majority and is self-enrolling for the Services. The Minor may not commence the Services unless and until either (i) a parent or legal guardian of the Minor (a “Parent/Guardian”) has authorized the Services by acknowledging Blossom’s Informed Consent, including Section G thereof, or (ii) applicable state law expressly authorizes the Minor to consent to the Services independently (see Section 6). The Minor’s enrollment, standing alone, does not authorize treatment. Blossom may require, verify, and rely upon the Parent/Guardian’s acknowledged Informed Consent before commencing the Services.
2. Representations Regarding Parent/Guardian Authorization
The Minor hereby represents, warrants, and attests to Blossom that:
(a) a Parent/Guardian has reviewed the nature of the Services and has authorized the Minor’s participation in therapy and, to the extent the Minor’s treating provider determines it to be clinically indicated, Medication Management (as defined below), including the prescribing of medication;
(b) such Parent/Guardian has acknowledged, or shall acknowledge prior to the Minor’s first appointment, Blossom’s Informed Consent, including Section G thereof; and
(c) the Parent/Guardian contact information furnished by the Minor is true, accurate, and complete; Blossom is authorized to contact such Parent/Guardian to verify the authorization described herein; and the Minor shall promptly inform Blossom of any change to such information.
“Medication Management” means the evaluation, recommendation, prescribing, and ongoing management of medication by a provider licensed to do so.
3. Consent to Participate in the Services
The Minor hereby consents to participate in the therapy and/or Medication Management Services determined appropriate by the Minor’s treating provider. The Minor acknowledges the right to ask questions, to decline any recommended treatment, and to revoke this Consent in writing at any time, except to the extent the provider has already taken action in reliance thereon. The Minor acknowledges receipt and review of Blossom’s Telehealth Consent and understands the manner in which the Services are furnished and the procedures applicable in an emergency.
4. Authorization to Disclose Records to Parent/Guardian
The Minor hereby authorizes Blossom to disclose to, and to permit access by, the Minor’s Parent/Guardian to the Minor’s complete chart and all chart notes relating to the Services (collectively, the “Minor Records”; Psychotherapy Notes are addressed separately in Section 5). The Minor acknowledges and agrees that the Minor’s acknowledgment of this Consent constitutes the Minor’s own consent and authorization for such disclosure, and that where applicable state law requires a minor’s separate consent or authorization for the disclosure of records to a parent or guardian, the Minor’s acknowledgment hereon shall satisfy, and is intended to satisfy, such requirement.
(a) Purpose. This authorization is made at the Minor’s request to permit the Parent/Guardian’s involvement in, and oversight of, the Minor’s care.
(b) Expiration. This authorization expires on the earliest of (i) the Minor’s written revocation, (ii) the date the Parent/Guardian ceases to authorize the Minor’s Services, and (iii) the Minor’s attainment of the age of majority, except to the extent the Minor then re-authorizes disclosure.
(c) Revocation. The Minor may revoke this authorization at any time by written notice to Blossom, except to the extent Blossom has already acted in reliance on it.
(d) Redisclosure; copy. Information disclosed under this authorization may be subject to redisclosure by the recipient and may then no longer be protected by federal privacy law. The Minor is entitled to a copy of this Consent.
(e) Clinical hold. Blossom may decline to disclose any particular record where, in the good-faith professional judgment of the treating clinician, disclosure would endanger the Minor or any other person, or where prohibited by law.
Where the Parent/Guardian is the Minor’s personal representative under applicable law, the Parent/Guardian also has a right of access to the Minor Records without further authorization, except as to Psychotherapy Notes.
5. Separate Authorization for Psychotherapy Notes
This Section 5 is a separate authorization, acknowledged separately from Section 4, as required by 45 CFR 164.508(a)(2). “Psychotherapy Notes” has the meaning given in 45 CFR 164.501.
The Minor hereby separately authorizes Blossom to disclose the Minor’s Psychotherapy Notes relating to the Services to the Parent/Guardian identified herein. The Minor’s separate acknowledgment of this Section 5 constitutes the Minor’s own consent and authorization for this disclosure and, where state law requires the minor’s separate consent, is intended to satisfy that requirement.
The Minor understands that (i) neither the individual’s right of access under 45 CFR 164.524 nor a personal representative’s authority extends to Psychotherapy Notes, so this separate authorization is required; (ii) this authorization is voluntary, and Blossom will not condition the Services on it; (iii) the treating clinician may decline to disclose Psychotherapy Notes in the exercise of professional judgment or where prohibited by law; and (iv) the Minor may revoke this authorization in writing at any time, except to the extent already relied upon.
6. Independent Consent Under State Law
Certain states permit a minor to consent to mental-health and/or medication services without a Parent/Guardian. Where the Minor resides in such a state and is consenting on that basis, the Minor shall so advise the treating provider. In that event, the Parent/Guardian shall not automatically be the Minor’s personal representative and shall not automatically have a right of access to the Minor Records or Psychotherapy Notes; such access shall be governed by the authorizations in Sections 4 and 5, which the Minor may decline or revoke, or as otherwise required by applicable law or court order.
7. Confidentiality; Mandatory Disclosures
Communications between the Minor and the Minor’s provider are confidential, subject to disclosures required or permitted by law, including the mandatory reporting of abuse or neglect and circumstances in which the Minor is a danger to the Minor or others. Further information is set forth in Blossom’s Notice of Privacy Practices, receipt of which the Minor hereby acknowledges.
8. Financial Responsibility
The Minor is not the financially responsible party for the Services. Financial responsibility is governed by Section F of the Parent/Guardian’s Informed Consent, pursuant to which the Parent/Guardian accepts responsibility for charges not paid by insurance. The Services will not commence until a Parent/Guardian has accepted such responsibility, except where the Minor independently consents under Section 6, in which case financial responsibility shall be addressed with the Minor and any responsible party at intake.
9. General Provisions
(a) Electronic Acknowledgment. The Minor and Parent/Guardian consent, under the federal E-SIGN Act and applicable Uniform Electronic Transactions Act, to the use of electronic records and electronic acknowledgments; an electronic acknowledgment has the same force and effect as a handwritten signature.
(b) Governing Law. This Consent is governed by the laws of the state in which the Minor is located when receiving the Services, without regard to conflicts-of-law principles.
(c) More Protective Law Controls. Where applicable state or federal law imposes requirements more protective of the Minor’s privacy or consent rights than this Consent, those requirements control, and the corresponding provisions of this Consent are deemed modified to comply.
(d) Severability. If any provision is held invalid or unenforceable in any jurisdiction, it shall be enforced to the maximum extent permissible and the remaining provisions shall remain in full force and effect.
(e) Order of Precedence. In the event of a conflict, the following order controls: applicable law; the Notice of Privacy Practices (as to privacy matters); this Consent and the Informed Consent; the Telehealth Consent; the Practice Policies.
(f) Reliance; Notice of Change. Blossom is entitled to rely on the representations herein, and the Minor and Parent/Guardian shall promptly notify Blossom of any change in Parent/Guardian status, custody, or decision-making authority.
10. Acknowledgment
By acknowledging this Consent, the Minor confirms that the Minor has read and understood it, has had the opportunity to ask questions and receive answers, and grants the consents and authorizations set forth in Sections 3 and 4.
Separate Acknowledgment — Psychotherapy Notes (Section 5). The Minor separately acknowledges and agrees to the authorization in Section 5 permitting the disclosure of the Minor’s Psychotherapy Notes to the Parent/Guardian. This acknowledgment is separate from, and in addition to, the acknowledgment above, and may be declined or revoked without affecting the Minor’s Services.
It is our obligation to provide you with the information you need in order to decide whether to consent to the treatment that you will be receiving. The purpose of this form is to verify that you have received this information and give consent to treatment. Please read this form carefully before acknowledging.
A. Treatment Information
Blossom BH Opco, Inc. provides therapy and medication management services for adults. Therapy is a process where mental health concerns and disorders are assessed, evaluated, and treated. There are a variety of techniques that can be used to provide relief and/or treat the mental health issues that have led you to seek therapy. These techniques and the therapy process have both benefits and risks. During appointments, you will discuss the nature of your mental health concerns, the goals of treatment, and any treatments your provider recommends. This discussion will also include the potential benefits, risks, or side effects of any recommended treatment, including potential medication that may be used in conjunction with therapy.
Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events in your life. Potential benefits include a significant reduction in feelings of distress, better relationships, improved problem-solving and coping skills, and resolution of specific problems. Given the nature of therapy, it is difficult to predict what exactly will happen, but your provider will use their best efforts to address the risks and benefits. The provider will discuss the likelihood of achieving your treatment goals and reasonable alternatives, and you will be actively involved in your mental health journey. You fully acknowledge that any benefit from therapy is directly dependent upon your participation and progression through therapy. However, no guarantees can be made regarding outcomes. At any time, you may refuse a recommended treatment or revoke your consent to the treatment altogether.
Your relationship with your provider is, and will always remain, professional. All parties will treat each other with respect at all times. You acknowledge that you have received information about your provider, including their qualifications and credentials (listed on the provider profile), and that you may ask about a provider’s qualifications and credentials either during appointments or by contacting Blossom BH Opco, Inc. If, at any time, you have concerns or complaints about your treatment, you may direct them to your provider or Blossom BH Opco, Inc.
B. Telehealth
Mental health services can be furnished using a number of different modalities, including telehealth, which allows you to seek care services using a secure audio or visual technology platform, rather than requiring you to come into an office for face-to-face appointments. Telehealth services are provided synchronously, meaning you and your provider will communicate in real time during a scheduled appointment over an audio/visual technology platform. There are many benefits to telehealth services, such as easier and more convenient access to services and receiving services from the comfort and safety of your home or workplace. However, there are also risks associated with telehealth services, including, but not limited to, technological failures, delays in response, and the limitations of therapy via electronic means. This section is intended to inform you of these risks, as well as the benefits, so that you may make an informed decision on whether or not to use telehealth services.
You understand that, in connection with telehealth services, your provider will be located at a remote location and will not be physically present with you. Your provider will communicate with you during scheduled telehealth appointments. Blossom BH Opco, Inc. has a secure platform that your provider can use to communicate with you via video, audio, or messaging communications. However, there always is a possibility that the transmission of your information could be disrupted or distorted by technical failures, or could be interrupted by unauthorized persons. To increase security, Blossom BH Opco, Inc. recommends that you avoid using public access computers or shared networks.
Telehealth has the same purpose or intention as psychotherapy, psychological treatment, and other mental health or counseling treatment that are conducted in person. However, due to the nature of the technology used, you may experience telehealth somewhat differently than face-to-face treatment appointments. Therefore, your provider will continuously assess whether telehealth is appropriate for your specific treatment needs.
It is important that you establish a plan with your provider in case you experience technological difficulties and get disconnected, or you experience a mental health crisis requiring in-person treatment.
If you get disconnected due to technological difficulties, your Blossom BH Opco Professional will contact you using your information on file with Blossom BH Opco, Inc. If you get disconnected during a mental health crisis, your Blossom BH Opco Professional will contact you, or if they are unable to reach you, your emergency contact. It is imperative that you ensure your, or your emergency contact’s, information is always up-to-date.
If you are experiencing an emergency situation, you must call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, you can call or text the National Crisis & Suicide Lifeline at 988 for free 24-hour hotline support.
C. Medication Management
If indicated, your provider may recommend certain medication(s) that may be used in conjunction with therapy. Your provider may only prescribe medications if they are licensed to do so in the state where they are licensed to provide services and if, in their professional judgment, the use of medication is medically indicated. As with therapy, there are potential benefits and risks associated with each medication. Your provider will discuss with you your options for mental health-related medications, the reasons for recommending medication, the proper usage of the medication, the potential side effects, and what to do if you experience any side effects. You have the right to refuse medication without any impact on your treatment relationship with your provider. If you choose to proceed with your Blossom BH Opco Professional’s recommendation for medication, they will provide you with a written prescription or will electronically transmit the prescription to a pharmacy of your choosing. Neither your Blossom BH Opco Professional nor Blossom BH Opco, Inc. will dispense medication to you directly. As with any medication, compliance with the medication’s prescribed usage is important for its effectiveness and to avoid negative side effects. As such, it is important that you understand and agree to the following:
Take any medications as prescribed.
Alert your provider to all medications, vitamins and/or supplements you are currently taking and alert them if you start or stop any medications, vitamins or supplements prescribed by another provider or of your own volition.
Discuss with your provider any side effects you may experience while taking the medication.
Do not stop taking medications without consulting with your provider, as doing so may result in negative side effects.
Do not share, sell, give away, dispense, or improperly dispose of your medication. If you do so, your provider and/or Blossom BH Opco, Inc. reserve the right to terminate your treatment relationship.
Certain laws or regulations may require you and your provider to have an in-person, face-to-face meeting at some point prior to or during your use of medication. Your provider will alert you if any such laws apply and will require you to comply with any in-person requirements before issuing a prescription or refill request.
If your provider is not authorized to prescribe medication, they may refer you to another provider who can assess the appropriateness of medication in your treatment and prescribe medication based on their professional judgment.
D. Confidentiality
Interactions with your provider will be confidential. There may be situations, however, where a provider is required by law to disclose certain information to certain parties, such as state agencies or law enforcement agencies. For example, your provider may be required by law to report abuse or neglect. Additionally, in the event that you are a danger to yourself or others, your provider may be required by law to take action that discloses certain information about you. Providers may also have a duty to warn anyone who may be in imminent danger as a result of your threats or frame of mind. Please ask your provider or Blossom BH Opco, Inc. if you have any questions about mandatory reporting situations.
E. Records
Your records will be stored securely for a minimum of ten years. Should you ever need access to your records, please contact Blossom BH Opco, Inc. You acknowledge that you have received the Blossom BH Opco, Inc. Notice of Privacy Practices, which outlines our record-keeping and Protected Health Information confidentiality procedures. All applicable confidentiality protections and ethical rules will apply to telehealth services in the same way as with in-person therapy.
F. Financial Information
You have received information on the fees that you will incur for services. You understand that you are financially responsible for charges that are not covered or paid by your insurance. You hereby consent to the release of information to third-party payors or their representatives as deemed necessary by Blossom BH Opco, Inc. to determine benefits entitlement and to process payment claims for services provided. You authorize and direct that payment of any health insurance or healthcare benefits otherwise payable to you for health care services will be paid directly to Blossom BH Opco, Inc. for the charges for which Blossom BH Opco, Inc. is authorized to bill in connection with the services provided to you. You certify that the information given by you in applying for payment is correct. You acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your insurance company or other payor. Charges are due and payable upon receipt of the bill.
If you have questions, you are encouraged and expected to ask them before you acknowledge this form. Your acknowledgment of this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By acknowledging this Informed Consent, you confirm and agree to the following:
You have been informed and have had an opportunity to ask questions and receive answers about the potential risks, limitations, alternatives, and benefits of receiving services, whether in-person or through telehealth, and, after considering such matters, you consent to receiving telehealth services if such modality is appropriate and desired.
No promises or guarantees have been made to you regarding the therapy or medication management services that you will receive.
You have provided, or will provide before treatment, Blossom BH Opco, Inc. with accurate and up-to-date personal, medical, and financial information necessary for your care and treatment.
You understand that you may revoke this consent in writing at any time, except to the extent that your provider has already taken action in reliance on it.
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If you or someone you know is experiencing an emergency or crisis and needs immediate help, call 911 or go to the nearest emergency room. Additional crisis resources can be found here.
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Questions?
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© 2026 Blossom Health
If you or someone you know is experiencing an emergency or crisis and needs immediate help, call 911 or go to the nearest emergency room. Additional crisis resources can be found here.
Get started
Questions?
Follow us
© 2026 Blossom Health
If you or someone you know is experiencing an emergency or crisis and needs immediate help, call 911 or go to the nearest emergency room. Additional crisis resources can be found here.