Form 10-601. Voluntary consent to voluntary admission for [residential treatment] [habilitation].

[For use with Section 32A-6A-20 NMSA 1978] STATE OF NEW MEXICO COUNTY OF _______________ __________________ JUDICIAL DISTRICT IN THE CHILDREN’S COURT STATE OF NEW MEXICO ex rel. CHILDREN, YOUTH AND FAMILIES DEPARTMENT No. __________ IN THE MATTER OF _______________________________ VOLUNTARY CONSENT TO VOLUNTARY ADMISSION FOR [RESIDENTIAL TREATMENT] [HABILITATION] ___________________________ (name of guardian or legal custodian) states that I am the parent, guardian, or legal custodian of __________________, a child under the age of fourteen (14) years, and that, pursuant to Section 32A-6A-20 NMSA 1978: (check applicable) ___ 1. I am voluntarily admitting my child to ____________________ (place admitted). ___ 2. I have been advised and understand that I have the right to voluntarily consent or refuse to consent to my child’s admission for treatment. ___ 3. I agree to my child participating in treatment programs based on my child’s individual needs as may be deemed appropriate by the treatment team. ___ 4. I understand that I have the right to request an immediate discharge of my child from the treatment program at any time. ___ 5. I understand that if I should request a discharge of my child and my child’s physician, licensed psychologist, or director of the residential treatment program determines that my child needs continued treatment, that on the first business day following my request for discharge, the children’s court attorney or district attorney may begin involuntary commitment proceedings. ___ 6. I understand that if involuntary commitment proceedings are filed, my child has a right to a court hearing on continued treatment within seven (7) days after my request that my child be discharged. ___ 7. My rights have been explained to me in the language of my preference, which is ________________ (specify language). ________________________________ (Parent) (guardian) (legal custodian) ________________________________ Date WITNESS I state that I have witnessed the signature of the above parent, guardian, or legal custodian and that I explained the contents of each of the numbered paragraphs to the parent, guardian, or legal custodian and to the minor child and I believe that they understand clearly the contents of those paragraphs. ________________________________ Witness ________________________________ Date