Informed Consent/Notice of Forensic Services (Minor/Guardian)

Date/Time: [Encounter date and time]

Location/Site: [Facility name and specific site/room]

Clinician(s) and Role(s): [Names, credentials, and forensic roles]

Service Type: [medical forensic exam / forensic mental health evaluation / other — specify]

Reason for Forensic Services: [Brief, factual reason services were requested] (Do not state allegations as conclusions)

Case Identifiers: [Facility MRN] | [External agency case number and source, or "Unknown"]

Parties Present and Identity Verification

(Use "Unknown," "Not present," "Declined," or "Unable to assess" when information is unavailable)

• Minor:
  • [Name or "Unknown"]
  • [Date of birth or "Unknown"]
  • [Identity verification method: ID band / government ID / caregiver attestation / CPS or law enforcement documentation / medical record / other]
  • [Developmental considerations relevant to assent capacity: communication needs, cognitive or behavioral factors, emotional state, age-appropriate understanding]
• Consenting Guardian:
  • [Full name]
  • [Relationship to minor]
  • [Legal authority basis: biological parent / legal guardian / custody order / agency with custody / foster placement / court-appointed representative / unknown]
  • [Verification of identity and authority: photo ID reviewed / court order reviewed / agency letter or placement paperwork / verified with agency or court / unable to verify]
  • (If authority uncertain or disputed) [Nature of uncertainty or dispute] | [Steps taken to verify] | [Interim decision and rationale]
• Others Present:
  • [Name or ID] | [Role: advocate / CPS / law enforcement / attorney / chaperone / child life specialist / other] | [Present during minor assent discussion: yes / no]
  • (Repeat for each additional person)
• Interpreter Use:
  • [Interpreter used: yes / no]
  • (If yes) [Interpreter name or ID] | [Modality: in-person / video / phone] | [Used for guardian consent: yes / no] | [Used for minor assent: yes / no]
  • (If no interpreter despite limited English proficiency) [Reason] | [Risk mitigation steps]

Forensic Role and Purpose Notice

(Document the role statement provided to guardian and minor; clearly differentiate clinical care from forensic functions)

• Role Statement Provided:
  • (For medical forensic services) [Explained dual purposes: health assessment and forensic documentation; medical care decisions are separate from evidence collection options]
  • (For forensic mental health evaluations) [Explained this is an evaluation, not therapy; role is objective; clinician cannot provide legal advice]
  • [Retaining or requesting party]
  • [Intended recipients of report or findings]
  • [Nature of deliverable: report / affidavit / testimony / records review / other]
  • (If dual-role or potential conflict exists) [Description of conflict] | [How addressed: role clarification / referral / supervision / separation of roles]

Confidentiality and Disclosure Notice

(Document disclosures discussed with guardian; specify recipients, content, legal authority, and limitations)

• [General notice provided that information will be recorded and may be disclosed as permitted or required by law]
• Anticipated Disclosures:
  • [Recipient] — [What may be shared] — [Mechanism: mandatory report / authorization / subpoena / court order / agency policy] — [Timing or limitations]
  • (Repeat for each applicable recipient: child protective services, law enforcement, prosecutor, court, attorneys, multidisciplinary team, treating providers, crime lab or evidence storage)
• [Limits on guardian access to certain minor health information, if applicable: legal or clinical basis; if uncertain, note facility approach]
• [Notice that records may be subject to legal process and clinician may be required to testify or produce records]

Guardian Consent

(Document consent as a process with components that may be accepted or declined independently. Guardian informed of right to withdraw or stop procedures at any time to the extent clinically and legally feasible. Do not document silence or lack of objection as consent.)

Medical Forensic Services Components

(Include only applicable components)

• Medical assessment and examination: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify limitations]
• Forensic evidence collection: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify items or sites]
• Photo-documentation: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify views permitted or storage restrictions]
• Toxicology testing: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify tests]
• STI and pregnancy testing and treatment: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify tests or treatments]
• Safety planning and follow-up contact: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify contact method or limits]
• Release of forensic kit to law enforcement: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred] | [Conditions or timing]

Forensic Mental Health Evaluation Components

(Include only applicable components)

• Interview and evaluation participation: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify scope limitations]
• Psychological testing: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify instruments]
• Collateral contacts: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify approved contacts]
• Records review: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred] | [Scope limitations]
• Audio or video recording: [Risks/benefits discussed: yes / no] | [Questions addressed: yes / no] | [Decision: consented / declined / deferred / partial — specify conditions]
• Release of report to specified recipients: [Recipients] | [Mechanism for release] | [Decision: consented / declined / deferred]
• Consultation with retaining party: [Scope of consultation] | [Decision: consented / declined / deferred]

Special Circumstances

(Include only if applicable)

• [Guardian absent / suspected of abuse / conflict of interest: circumstances and how addressed]
• [Court-ordered evaluation without consent requirement: order details; notice provided to guardian and minor]
• [Consent refused: stated reasons if offered; accommodations attempted; alternative plan]

Minor Assent

(Document developmentally appropriate explanation, assessment of understanding and undue pressure, and willingness to proceed. Do not record assent as obtained when the minor's refusal will not be respected; instead document required care with supportive explanation provided.)

• [Explanation provided to minor: what is happening, why, and what to expect]
• [Understanding assessed: method and outcome]
• [Assessment for undue pressure or coercion: observations]
• [Assent outcome: assented / declined / unable to assent — reason]
• (If partial assent) [Components agreed to] | [Components declined]
• (If dissent) [Cues observed: verbal refusal / pulling away / crying / withdrawal / other] | [De-escalation attempts and accommodations offered] | [Outcome: procedure stopped / deferred / proceeded with required care only] | [Supportive explanation provided]

Evidence Handling

(Include only if forensic evidence was collected or transferred)

• [Items collected and labeling method]
• [Collection time(s) and storage location]
• [Kit number and type]
• [Chain of custody: name or ID, transfer time, receiving agency — repeat for each transfer]
• [Photographs: description; storage location; access controls] (Do not attach images; reference storage location only)

Signatures and Attestations

• Guardian: [Signature method: written / verbal] | [Printed name and relationship] | [Date/Time]
  (If verbal) [Who heard consent and reason written signature not obtained]
  (If not obtained) [Reason]
• Minor: (Optional; include only when appropriate and not coercive)
  [Signature or initials obtained: yes / no] | [Date/Time] | [Reason if not obtained or not appropriate]
• Clinician: [Name and credentials] | [Signature] | [Date/Time]
• Witness: (If required by policy)
  [Name and role] | [Signature] | [Date/Time]
• Interpreter Attestation: (If interpreter used)
  [Interpreter name or ID] | [Attests to accurate and complete interpretation: yes / no] | [Date/Time]

(Omit sections not applicable to the encounter. Use explicit placeholders when information is unavailable.)