Counseling
and Consent for Minors
Counseling and Consent for Minors (less than 18 years
of age) at time of procedure
All minors must be accompanied by a parent or guardian, or a person 21 or more years of age who is not associated with the clinic, and has a personal interest in the minor's well-being. This person shall be involved in the minor's decision-making process regarding whether to have an abortion.
I certify that I am attending counseling with ___________________________________ . My relationship with her is ___________________________________________.
_____________________________________________________ Date
_______________________
Name of accompanying adult
It is important to understand that the decision of the minor to have an abortion can be changed up until the moment the physician begins the termination procedure. The abortion may be performed up until the point of fetal viability. Wichita Family Planning, Inc. only performs this procedure through the twelfth (12th) week of pregnancy.
It is always advisable to consider discussing with a parent, guardian, or family member the options available to women. This decision should be made with all due consideration of all options available, including abortion, adoption, and other alternatives to abortion. The decision ultimately remains that of the patient.
Before performing the abortion, actual notice of intent must be given to one of the minor's parents or the minor's legal guardian or written documentation that such notice has been given must be obtained. Actual notice may be documented by the parent's or legal guardian's signature, before a Notary, on the Waiver of Notification form.
After counseling, if the minor objects to notification of the parent or legal guardian, the minor may request of the Court that notice be waived. The counselor shall assist her in obtaining an anonymous hearing for consideration of waiver. The minor's identity is kept confidential. No fees are necessary. The case will be determined within forty-eight (48) hours of filing.
The clinic shall make available to the minor information on agencies available to assist the minor and agencies from which birth control information is available, upon request (see If You Are Pregnant: Directory of Services).
Pre-abortion counseling has been provided including, but not limited to, information discussed herein, and post-abortion counseling shall be provided. Please feel free to contact us at any time you need additional counseling or service.
The undersigned have read and understand the above information regarding the possible decision to terminate this pregnancy, and the undersigned have engaged in counseling as discussed herein.
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Patient's Signature
________________________________________________
Accompanying Adult's Signature
________________________________________________
Counselor's Signature
________________________________________________
Counselor's Business Address
________________________________________________
City, State and Zip
________________________________________________
Business Phone
