New Mexico Forms Library

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

[Approved, effective July 1, 2002; 10-491 recompiled and amended as 10-601 by Supreme Court Order No. 14-8300-009, effective for all cases filed or pending on or after December 31, 2014.]