Private Access Psychiatry

Minor Intake Confidentiality Agreement

This agreement accompanies the Minor Intake Packet and is intended to support a private, respectful intake process for the patient and parent or legal guardian.

Important: This document is an administrative confidentiality acknowledgment. It does not replace the practice’s Notice of Privacy Practices, informed-consent materials, emergency guidance, or any legal rights and obligations that apply to care.

Confidential handling of intake information

I understand that the intake packet may contain sensitive health information. I will use the practice’s secure intake process to return completed materials and will avoid sending completed forms through ordinary email, text message, or other unsecured channels.

Parent or guardian responsibilities

I confirm that I am authorized to provide information for the minor patient. I agree to keep portal access private, provide accurate information, and notify the practice promptly if I believe an account or document may have been accessed by someone else.

Privacy and questions

I understand that confidentiality, parent or guardian access, and the minor patient’s privacy are governed by applicable law and the practice’s privacy and consent materials. I may contact Private Access Psychiatry with questions before signing or submitting this acknowledgment.

Minor patient name

Parent or legal guardian name

Parent or legal guardian signature

Date