Form CFS 431-1 Consent of Guardian to Mental Health Treatment - Illinois

Form CFS431-1 or the "Consent Of Guardian To Mental Health Treatment" is a form issued by the Illinois Department of Children and Family Services.

The form was last revised in April 1, 2017 and is available for digital filing. Download an up-to-date Form CFS431-1 in PDF-format down below or look it up on the Illinois Department of Children and Family Services Forms website.

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CFS 431-1
State of Illinois
Rev 4/2017
Department of Children and Family Services
CONSENT OF GUARDIAN TO MENTAL HEALTH TREATMENT
As the legal custodian/guardian of
,
a
minor
whose birth date is
, I am authorized to act, pursuant to 705 ILCS 405/2-11 or 705 ILCS
405/2-27, on behalf of the individual minor in making health care decisions, and I hereby consent to mental
health treatment (excluding inpatient psychiatric hospitalizations and psychotropic medications) for the
individual minor.
Therapy
Counseling
Psychological Assessment
Medication Monitoring
Psychological Evaluation
EEG’s and EKG’s
Psychiatric Evaluation
Blood Level Check
It is understood that such treatment will take place at
(Name, address and telephone number)
THE ABOVE CONSENT IS VALID UNTIL
AND IS SUBJECT TO THE FOLLOWING SPECIAL CONDITIONS:
The costs, nature and purpose of the treatment, possible alternative treatments, and the potential risks and
benefits of the treatment have been explained to me. I understand that my refusal to consent to any of the above
services may result in these consequences:
I retain the right to revoke this authorization with written notice to the above-named provider prior to the
expiration date. This authorization is valid until the minor is released from the specified treatment and/or
procedure, or until
/
/
.
Date
DCFS Guardianship Administrator
Witness
By
Authorized Agent
Address:
cc:
Telephone:
(Service Office)
(8:30 a.m.-5:00 p.m.)
(Evenings, Weekends, Holidays)
NOTE: THE CONSENT OF MINOR 12 YEARS OF AGE OR OLDER IS ALSO REQUIRED
SIGNED:
DATE:
(Signature of person 12 years of age or older)
Distribution:
One copy to MH Provider
One to Case Record
One to Substitute Caregiver
One to Minor (if 12 years or older)
CFS 431-1
State of Illinois
Rev 4/2017
Department of Children and Family Services
CONSENT OF GUARDIAN TO MENTAL HEALTH TREATMENT
As the legal custodian/guardian of
,
a
minor
whose birth date is
, I am authorized to act, pursuant to 705 ILCS 405/2-11 or 705 ILCS
405/2-27, on behalf of the individual minor in making health care decisions, and I hereby consent to mental
health treatment (excluding inpatient psychiatric hospitalizations and psychotropic medications) for the
individual minor.
Therapy
Counseling
Psychological Assessment
Medication Monitoring
Psychological Evaluation
EEG’s and EKG’s
Psychiatric Evaluation
Blood Level Check
It is understood that such treatment will take place at
(Name, address and telephone number)
THE ABOVE CONSENT IS VALID UNTIL
AND IS SUBJECT TO THE FOLLOWING SPECIAL CONDITIONS:
The costs, nature and purpose of the treatment, possible alternative treatments, and the potential risks and
benefits of the treatment have been explained to me. I understand that my refusal to consent to any of the above
services may result in these consequences:
I retain the right to revoke this authorization with written notice to the above-named provider prior to the
expiration date. This authorization is valid until the minor is released from the specified treatment and/or
procedure, or until
/
/
.
Date
DCFS Guardianship Administrator
Witness
By
Authorized Agent
Address:
cc:
Telephone:
(Service Office)
(8:30 a.m.-5:00 p.m.)
(Evenings, Weekends, Holidays)
NOTE: THE CONSENT OF MINOR 12 YEARS OF AGE OR OLDER IS ALSO REQUIRED
SIGNED:
DATE:
(Signature of person 12 years of age or older)
Distribution:
One copy to MH Provider
One to Case Record
One to Substitute Caregiver
One to Minor (if 12 years or older)

Download Form CFS 431-1 Consent of Guardian to Mental Health Treatment - Illinois

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