Minor’s Mental Health Non-Disclosure Form

Hawaii state law (HRS 577-29) provides minors age 14 through 17 years old the right to restrict information about their mental health treatment and services from being disclosed to the minor’s parents/guardian.

The law also provides that mental health professionals involved in treatment may assist minors in completing and submitting a request for non-disclosure to a health plan.

Please use this form to submit a request for non-disclosure of mental health treatment or services on behalf of a minor patient.

Minor’s Mental Health Non-Disclosure Form [PDF]

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