MINOR CONSENT & CONFIDENTIALITY IN ALABAMA

This guide is dedicated to addressing health provider concerns about confidentiality

laws, minor consent laws, and reporting responsibilities for healthcare providers

in an effort to increase access to and use of youth-friendly healthcare in Alabama.

MINOR CONSENT

& CONFIDENTIALITY

IN ALABAMA

May 2021

Alabama Child Health

Improvement Alliance

achia.org

Alabama Department

of Public Health

alabamapublichealth.gov

TABLE OF CONTENTS

A Resource for ALL Health Center Staff ........................................................................... 1

Age of Consent for Healthcare

............................................................................................3

Minor Consent Laws: Sexual & Reproductive Health Services

.................................4

Minor Consent Laws: Mental Health & Substance Abuse Services

........................5

Title X Services

.......................................................................................................................... 6

Tips to Ensure Confidentiality

............................................................................................... 7

Youth-Friendly Best Practice: No- or Low-Cost Services

.......................................... 8

Mandatory Reporting Responsibilities

............................................................................. 9

Reporting Form

.........................................................................................................................11

References

.................................................................................................................................13

By clarifying minors’ consent and confidentiality rights, this guide helps health center staff

take this first critical step to ensure access to youth-friendly healthcare in Alabama.

This booklet is an adaptation of Teen Health Mississippi’s “Minor Consent & Confidentiality in Mississippi” booklet.

Teen Health Mississippi granted permission for use of their copyrighted work, but retains all exclusive rights to

distribute, reproduce, perform, license and display the “Minor Consent & Confidentiality in Mississippi” booklet.

In 2016, Alabama ranked

ninth in the nation for teen

childbearing, with a rate of

28.4 births per 1,000 teen girls

aged 15-19.

In 2015, among those surveyed

for the Youth Risk Behavior

survey, 46% of Alabama high

school students reported ever

having sex. Thirty-five percent

of Alabama high school

students reported being

currently sexually active.

70% of Alabama high school

students that reported being

currently sexually active did

not use birth control pills; an

IUD or implant; a shot; a patch;

or a birth control ring before

last sexual intercourse; and

49% did not use a condom.

Studies have shown that teens usually trust their doctors to maintain their confidentiality, but many

worry that receptionists, technicians, and nurse assistants might break their confidentiality.

These statistics may be a contributing factor to Alabama’s low rates of contraceptive use and, in

turn, high rates of teen pregnancy and teen births, including repeat births to teens.

A Resource for ALL Health Center Staff

86% of adolescent female

family planning clients

would be willing to use all

of the confidential sexual

health services offered at

local clinics.

29% would have

unprotected sex if

their parents were

to be notified.

83% would stop using

some or all sexual health

services if their parents

were to be notified.

6% would delay testing

or treatment for HIV and

other STDs if their parents

were to be notified.

57% would stop using

prescription contraceptives

and begin using condoms

instead if their parents

were to be notified.

Only 1% would stop

having sex if their parents

were to be notified.

Fewer than 4% of girls aged 15-19 years in Alabama seeking contraceptive services at Title X service sites

in 2013 used long-acting reversible contraception (LARC).

The importance of confidentiality for teens

when accessing contraceptive services, including LARC services, is illustrated by the following statistics

from a study on adolescent female family planning clients:

It is widely known that teens’ concern about confidentiality is the #1 reason they

might not seek medical care.

The various confidentiality laws, minor consent laws,

and reporting responsibilities can be overwhelming and confusing to healthcare

providers, teens, and parents. This resource is meant to simplify these issues.

ALABAMA STATE LAW generally requires parental consent or notification before a minor

less than 14 years of age may obtain contraceptive services.

HOWEVER, if a minor is

seeking services at a TITLE X funded site, Title X providers must allow minors to obtain

Title X services on their own consent, even if state law explicitly requires parental consent

or notification for such services.

(See page 6 for more information about Title X.)

MEDICAID

Minors are allowed to receive family planning services that are paid for by Medicaid

based on their own consent and on a confidential basis. Federal Medicaid law contains

safeguards against disclosure of confidential information.

It also requires that Medicaid

cover family planning “services and supplies” for all Medicaid enrollees of childbearing

age, including “minors who can be considered to be sexually active.”

This applies in any

setting that provides Medicaid-funded services, not just Title X-funded sites.

Certain minors less than 14 years of age may consent for healthcare in Alabama.

• Under 14 years of age but has graduated high school.

• Under 14 years of age but married.

• Under 14 years of age but formerly married and now divorced.

• Under 14 years of age but pregnant.

• Under 14 years of age but a parent.

AGE OF CONSENT FOR HEALTHCARE IN ALABAMA

The general age of consent for healthcare in Alabama is 14 years old.

Title X Law always trumps Alabama State Law.

This chart describes the sexual and reproductive health services that

minors in Alabama may obtain on their own consent. All Title X-funded sites

MUST follow Title X requirements.

How do your clinic’s policies line up?

ALABAMA MINOR CONSENT LAWS: SEXUAL AND REPRODUCTIVE HEALTH SERVICES

TYPE OF SERVICE ALABAMA STATE LAW TITLE X LAW (ALWAYS TRUMPS STATE LAW)

Contraceptive

Services

Minors 14 years of age and older may

consent; minors of any age may consent

if they have graduated high school,

married, married and divorced, or are a

parent.

Adolescents may consent to contraceptive

services covered by Title X, regardless of age. This

includes the pill, patch, ring, and LARC devices

(e.g., implant, IUD).

STD Testing &

Treatment (not

including HIV)

Minors age 12 and older may consent

for STD testing and treatment.

Adolescents may consent to STD testing and

treatment covered by Title X, regardless of age.

HIV Testing &

Treatment

Minors age 12 and older may consent for

HIV testing and treatment under Code

of Alabama § 22-11A-19.

Adolescents may consent to HIV testing, regardless

of age. Title X does not cover HIV treatment.

Emergency

Contraception (EC)

Alabama does not currently have any

law regarding EC.

Adolescents may consent to contraceptive

services covered by Title X (including EC services),

regardless of age.

Prenatal Care,

Childbirth, and

Adoption Services

• Minors of any age may consent to

prenatal care and childbirth services.

• Minors of any age may consent to

medical care for their child.

ALABAMA MINOR CONSENT LAWS: MENTAL HEALTH & SUBSTANCE ABUSE SERVICES

CONTEXT

Research shows that there are strong relationships between mental and sexual health.

Many young people experience

mental health challenges and/or substance abuse that may not only influence their sexual risk behaviors and sexual

health needs, but impact their overall health and well-being.

21, 22

Access to youth-friendly services for substance abuse

and mental health concerns is just as important as for sexual and reproductive healthcare. By promoting access to and

use of youth-friendly mental health and substance abuse treatment, healthcare providers can help adolescents cope with

the complex realities associated with adolescence.

ALABAMA STATE LAW allows a minor of any age to consent to services for problems related to alcohol or drugs without

parental consent.

FEDERAL CONFIDENTIALITY RULES for drug and alcohol treatment programs contain protections that apply to minors

as well as adults, particularly when minors may consent to their own drug- and alcohol-related care under state law.

Careful analysis of the relationship of these rules to Alabama law is required to determine when information may and

may not be disclosed to parents in specific treatment settings.

Approximately 29% of Alabama high

school students that were surveyed

reported depression symptoms

during the previous 12 months and

18% reported that they seriously

considered attempting suicide.

A 2013 study found that less

than 50% of the adolescents

with psychiatric disorders

received any kind of treatment

in the previous year.

TITLE X SERVICES MUST BE CONFIDENTIAL

Adolescents seeking contraceptive services in Alabama may go to any Title X clinic for

a wide range of confidential contraceptives and related preventive services without

parental consent. Title X is a federal program enacted in 1970 as part of the

Public Health

Service Act

and is devoted entirely to the delivery of contraceptive and other related

preventive services. Title X staff members are specially trained to meet the contraceptive

needs of their clients, including adolescents.

Title X regulations require that each Title X-funded project must provide a broad range

of acceptable and effective family planning methods and related preventive services,

including services for adolescents.

CONFIDENTIALITY PROTECTIONS IN TITLE X REGULATIONS:

Title X clinics must have written policies in place that protect confidentiality while also

encouraging family participation in the decision of minors to seek family planning services.

In addition, Title X providers must comply with any state law requiring notification or the

reporting of child abuse, child molestation, sexual abuse, rape, or incest.

TITLE X REGULATIONS REQUIRE THAT:

“All information as to personal facts and circumstances obtained by the project staff about

individuals receiving services must be held confidential and must not be disclosed without

the individual’s documented consent, except as may be necessary to provide services

to the patient or as required by law, with appropriate safeguards for confidentiality.

Otherwise, information may be disclosed only in summary, statistical, or other form which

does not identify particular individuals.”

Alabama’s Title X-funded

health centers provide a

wide range of services:

• Pregnancy testing

• Contraceptive services

• Pelvic exams

• Screening for cervical

and breast cancer

• Screening for high

blood pressure, anemia,

and diabetes

• Screening for STDs

and HIV/AIDS

• Infertility services

(Level 1 and 2)

• Health education

• Referrals for other

health and social

services

• Reproductive life

plan counseling

For more information about Title X clinics, visit www.hhs.gov/opa/title-x-family-planning.

TIPS TO ENSURE CONFIDENTIALITY

ADVOCATES FOR YOUTH provides the following recommendations to ensure confidentiality for teen clients:

HIPAA PRIVACY RULE

The HIPAA Privacy Rule contains detailed requirements for protecting the confidentiality of individuals’ health information

and includes specific requirements related to the health information of minors.

The rule generally allows parents to

have access to minors’ protected health information, with some exceptions.

When minors are legally allowed to consent to their own care, and have consented to care, or when parents have agreed

that the care can be confidential, parents’ access depends on state law or other applicable law, such as Title X law. If state

or other applicable law contains clear requirements prohibiting, requiring, or permitting disclosure of information to parents,

those requirements are controlling. If state or other applicable laws are silent on the question of parents’ access, healthcare

providers exercising professional judgment have discretion to decide whether to disclose minors’ information to parents.

Alabama laws that allow minors age 14 or older to receive healthcare without parental consent (and therefore to give their

own consent for those services) are silent on the question of disclosure of the information. Alabama law regarding STD testing

and treatment for minors that are 12 and older gives a provider the discretion to inform the parent or guardian of the minor.

Federal laws, such as Title X,

Medicaid,

31,32

and the federal confidentiality rules for drug and alcohol treatment programs

contain specific protections that allow minors to receive care without disclosure of the information to their parents.

1. Make sure that all clinic staff members have a clear

understanding of Alabama’s state laws on informed

consent and confidentiality with regards to

a. Contraceptive services,

b. STD testing and treatment,

c. HIV testing and treatment,

d. Substance abuse treatment, and

e. Mental healthcare.

Emphasize the

protection

of confidentiality.

3. Train all clinic staff members about the importance

of guarding teens’ confidentiality. Ensure that all

receptionists, medical assistants, technicians, and

clinical providers understand the importance of

maintaining confidentiality, especially for youth patients.

4. When a teenage client is accompanied to the clinic

by a parent or guardian, make sure to always have

counseling time alone with the teen client.

5. Be willing to treat unaccompanied teens.

YOUTHFRIENDLY BEST PRACTICE: NO OR LOWCOST SERVICES

Fear about costs is a major barrier to healthcare for youth. Advocates for Youth

provides the following

recommendations on costs to improve a health center’s youth-friendliness:

1. Offer free or greatly reduced-fee services to adolescents. This can be especially important for STD testing and treatment.

2. Set-up private billing accounts for adolescents who seek confidential services. Arrange for laboratory fees for

confidential tests to be billed directly to the clinic or practice. Establish a nominal payment plan with the adolescent.

At the same time, bill the adolescent’s insurance for provider time, using non-confidential codes, so that information

forms sent to the parents will not betray youth’s confidentiality.

3. Where permitted by state law, dispense no- or low-cost prescriptions to adolescents.

4. Stock exam rooms (not the waiting room) with baskets of condoms along with signs saying that youth are free to take

as many as they feel they need, at no charge.

MEDICAID FAMILY PLANNING WAIVER

The Medicaid Family Planning Waiver allows the state of Alabama to provide Medicaid benefits for family planning and family

planning-related services. If your health center accepts Medicaid, clients should be educated as to the benefits of the

Medicaid Family Planning Waiver program, Plan First, and the significance to its participants, and the services provided.

WHO IS ELIGIBLE? COVERED SERVICES

• Women and men between the ages of 19-55.

• Family income is at or below 146% of the

federal poverty level.

• Must not have Medicare, Children’s Health

Insurance Program (CHIP) coverage, or

any other health insurance or third-party

medical coverage.

• Women cannot be pregnant.

• Four (4) annual visits to a Medicaid-accepting provider.

• Family planning and family planning-related services

such as the IUD, implant, depo, pills, patch, ring,

diaphragm, and condoms.

• Testing and treatment of sexually transmitted

diseases (STDs) and abnormal pap smears.

• Covers Human Papillomavirus (HPV) vaccine.

• Voluntary sterilization.

Beneficiaries enrolled in the Family Planning Waiver Program may have a prescription for contraceptives and/or medications

to treat an STD written by any Medicaid-participating provider filled at their local Medicaid-participating pharmacy.

Health Center staff should assist clients with submitting applications for the Medicaid Family Planning Waiver Program. A

Family Planning Waiver Application, a copy of the client’s proof of income, a copy of the client’s birth certificate or Electronic

Verification of Vital Events printout, and a copy of the client’s picture ID must be submitted to the Division of Medicaid.

For more information about the Plan First program, information for providers, and other resources, visit www.medicaid.alabama.gov.

YOUTHFRIENDLY BEST PRACTICE: NO OR LOWCOST SERVICES

CHILD ABUSE FAQS

What is child abuse?

Under Alabama law, it is “harm or threatened harm to a child’s health or welfare which can occur through nonaccidental

physical or mental injury; sexual abuse or attempted sexual abuse; sexual exploitation or attempted sexual exploitation.”

What is child neglect?

Under Alabama law, it is “negligent treatment or maltreatment of a child, including the failure to provide adequate

food, medical treatment, clothing, or shelter: provided, however, that a parent or guardian legitimately practicing his

religious beliefs who thereby does not provide specified medical treatment for a child, for that reason alone shall not

be considered a negligent parent or guardian; however, such an exception shall not preclude a court from ordering that

medical services be provided to the child, where his health requires it.”

Must I report suspected child abuse and/or neglect?

Some people are required, by law, to report suspected abuse or neglect, but anyone is encouraged to make a report if he

or she suspects a child is being abused or neglected. Those required, by law, to report include doctors, surgeons, medical

examiners, coroners, dentists, osteopaths, optometrists, chiropractors, podiatrists, nurses, school teachers and officials,

law enforcement officials, pharmacists, social workers, day care workers or employees, and mental health professionals.

Also required to report are persons called upon to render aid or medical assistance to any child when the child is known

or suspected to be a victim of abuse or neglect.

How can I be certain that a child has been abused or neglected?

Certainty is not required. In most instances, the only way you could be absolutely certain that a child had been abused or

neglected would be if the parent or other person admitted it. All that is required is a reasonable suspicion that a child is a

victim of abuse or neglect. After investigating the report, the department determines whether abuse and/or neglect occurred.

To whom must I report?

You should make your report to your chief of police or sheriff, or to the Department of Human Resources. When a report

is made to a law enforcement official, he must inform the department so that protective services to the child or children

involved may be provided.

When must I report?

If you are among those persons required to report child abuse and neglect and you learn of a child whose condition

or injuries are not reasonably explainable as accidental, or if you are called on to treat such injuries, you must report

immediately by telephone or in person. The law also requires you to follow your oral report with a written one. The

Department of Human Resources has a form for your written report.

Alabama Code - Section 26-14-3 — Mandatory reporting.

(a) All hospitals, clinics, sanitariums, doctors, physicians, surgeons, medical examiners, coroners, dentists, osteopaths, optometrists,

chiropractors, podiatrists, nurses, school teachers and officials, peace officers, law enforcement officials, pharmacists, social

workers, day care workers or employees, mental health professionals, members of the clergy as defined in Rule 505 of the Alabama

Rules of Evidence, or any other person called upon to render aid or medical assistance to any child, when the child is known or

suspected to be a victim of child abuse or neglect, shall be required to report, or cause a report to be made of the same, orally,

either by telephone or direct communication immediately, followed by a written report, to a duly constituted authority.

Prepared by the Public Affairs Office for the: Family and Children’s Services Division, Office of Protective Services State of

Alabama, Department of Human Resources

What must I report?

Both oral and written reports should include the name of the child, his whereabouts, the names and addresses of the

parents or guardian, and a description of the child’s condition.

Don’t delay reporting if you don’t have all of this information, as it can be obtained later.

How am I protected?

All persons reporting suspected abuse or neglect (whether required by law to report or not) are presumed to be acting in

good faith. They are, by law, immune from legal action, civil or criminal, that might otherwise be taken. Thus, you have full

protection in the event a parent or someone else should seek to initiate action against you.

Will I have to testify in court?

That depends on the nature and severity of the case, whether court action is initiated to remove the child from the home,

and whether the alleged party is prosecuted on a criminal charge.

The law is specific: “the doctrine of privileged communication shall not be a ground for excluding any evidence regarding

a child’s injuries or the cause thereof.”

What happens to the child?

Generally, Alabama law requires the Department of Human Resources “to seek out, through investigation, complaints from

citizens, or otherwise, the minor children…in need of its care and protection and … aid such children to a fair opportunity in life.”

The department works closely with the child and the parents or caretaker through direct counseling or referral to appropriate

helping professionals or agencies. The purpose of providing these services is to keep the family unit together, if possible.

If removal of the child from his home is necessary, the department will petition the court for custody and make plans for

substitute care of the child.

The department will continue to work with the child and seek to work with the parents to prepare them for the time when

the child may be returned to their home or receive continued care elsewhere.

______________________________________________________________________________________________________________

All programs of the Department of Human Resources are administered in accordance with the Civil Rights Act of 1964 and

the Rehabilitation Act of 1973.

Prepared by the Public Affairs Office for the: Family and Children’s Services Division, Office of Protective Services

State of Alabama, Department of Human Resources

DHR Pamphlet Series 76-2

Revised 7-88

Accessed 5/13/2021 - https://dhr.alabama.gov/child-protective-services/child-protective-services-faq/

Alabama Code - Section 13A-6-61 - Rape First Degree

(a) A person commits the crime of rape in the first degree if he or she does any of the following:

(1) engages in sexual intercourse with another person by forcible compulsion.

(2) Engages in sexual intercourse with another person who is incapable of consent by reason of being incapacitated.

(3) Being 16 years old or older, engages in sexual intercourse with another person who is less than 12 years old.

(b) Rape in the first degree is a Class A felony.

Alabama Code, Section 13A-6-62 - Rape Second Degree

(a) A person commits the crime of rape in the second degree if, being 16 years or older, he or she engages in sexual

intercourse withanother person who is 12 years old; or older, but less than 16 years old; provided, however, the actor is

at least two years older than the otherperson.

(b) Rape in the second degree is a Class B felony.

DHR-FCS-1593 (September 2002)

STATE OF ALABAMA DEPARTMENT OF HUMAN RESOUCES

WRITTEN REPORT OF SUSPECTED CHILD ABUSE/NEGLECT

Please print or type all known information. The Child Abuse/Neglect Reporting Law and instructions are explained on the back of this form.

SECTION I – CHILDREN ALLEGEDLY ABUSED OR NEGLECTED

NAME (First, Middle Initial, Last) SEX ETHNICITY DATE OF BIRTH/AGE

1. _________________________________________________________________ M F ________________ ____________________

2. _________________________________________________________________

M F ________________ ____________________

3. _________________________________________________________________

M F ________________ ____________________

4. _________________________________________________________________ M F ________________ ____________________

5. _________________________________________________________________

M F ________________ ____________________

6. _________________________________________________________________

M F ________________ ____________________

ADDRESS _______________________________________________________________________________________________________________________

Street Address City State Zip Telephone Number

SECTION II – OTHER PERSONS LIVING WITH THE CHILDREN (Include parents/custodians and other children in the home)

NAME (First, Middle Initial, Last) DATE OF BIRTH / AGE ETHNICITY RELATIONSHIP TO

THE CHILDREN

1. ________________________________________________________________ ____________________

________________

_________________

2. ________________________________________________________________ ____________________

________________

_________________

3. ________________________________________________________________ ____________________

________________

_________________

4. ________________________________________________________________ ____________________

________________

_________________

5. ________________________________________________________________ ____________________

________________

_________________

6. ________________________________________________________________ ____________________

________________

_________________

SECTION III – PERSON(S) ALLEGEDLY RESPONSIBLE FOR THE ABUSE OR NEGLECT

NAME (First, Middle Initial, Last) SEX ETHNICITY DATE OF BIRTH / AGE

1. _________________________________________________________________ M F ________________ ____________________

_________________________________________________________________

Street Address City State Zip Telephone Number

______________________________________________________

Relationship To Children Allegedly Abused/Neglected

2. _________________________________________________________________

M F ________________ ____________________

_________________________________________________________________

Street Address City State Zip Telephone Number

______________________________________________________

Relationship To Children Allegedly Abused/Neglected

SECTION IV – ABUSE OR NEGLECT ALLEGATIONS (Describe what happened, how it affected the children, and the date(s) occurred, if known.

________________________________________________________________________________________________________________________________

________________

________________________________________________________________________________________________________________

Did you see the abuse or neglect when it occurred? Yes No If no, how did you find out about it? ______________________________________

Please identify other people who witnessed the abuse/neglect or who may have information about the child’s or family’s situation.

Name Address Telephone # Relationship to Children

1. ________________________________________

__________________________________________ ______________ ________________________

2. ________________________________________

__________________________________________ ______________ ________________________

SECTION V - OTHER PERTINENT INFORMATION

________________________________________________________________________________________________________________________________

SECTION VI - REPORTER

_________________________________________________________________________________________________________________________________________________

Name Address Telephone Number Title/Agency/Relationship To Children

Did you verbally report the allegations to the Department of Human Resources or law enforcement? Yes (specify to whom in section below) No

______________________________________________ _____________________________________________________ ________________________

Name Name of County DHR, Police Department, or Sheriff’s Department Date Reported

Signature _______________________________________________________________________

Date ____________________________________________

For DHR Use Only County _______________________________ Case #____________________________ Date Report Received _____________________

REFERENCES

DHR-FCS-1593 (September 2002)

EXPLANATION OF CERTAIN PROVISIONS OF THE CHILD ABUSE/NEGLECT REPORTING LAW

(Code Of Alabama 1975, Sections 26-14-1 through 26-14-13)

In order to protect children whose health and welfare may be adversely affected through abuse and neglect, this law

provides for the reporting of such cases to appropriate authorities. The law also contains immunity provisions so that any

person making a report pursuant to the statute is immune from any civil or criminal liability that might otherwise be

incurred or imposed.

The following institutions and pers

ons are required by law to report known or suspected child abuse or neglect under a

penalty of a misdemeanor, fine or sentence: hospitals, clinics, sanitariums, doctors, physicians, surgeons, medical

examiners, coroners, dentists, osteopaths, optometrists, chiropractors, podiatrists, nurses, school teachers and officials, peace

officers. law enforcement officials, pharmacists, social workers, day care workers

or employees, mental health

professionals, or any other person called upon to render aid or medical assistance to a child when that child is known or

suspected to be abused or neglected. In addition, any other person may make a report if that person has reasonable cause to

suspect that a child is being abused or neglected.

INSTRUCTIONS

Print or type all known information.

SECTION I

- CHI

LDREN ALLEGEDLY ABUSED OR NEGLECTED

Enter identifying information (name, sex, ethnicity, date of birth or approximate age) for each child in the family who is

suspected to be abused or neglect. If the report is for more than one (1) child and they are not all members of the same

family, a separate report (1593) must be completed. This includes if the children live in separate

households or are a separate family within the same household.

Enter the child(ren)’s address and telephone number.

SECTION II - OTHER PERSONS LIVING WITH THE CHILDREN

Enter identifying information (name, date of birth or approximate age, ethnicity, and relationship) for each person living in

the home with the child(ren) named in Section I.

SECTION II

I - PERSON(S) ALLEGEDLY RESPONSIBLE FOR ABUSE OR NEGLECT

Enter identifying information (name, sex, ethnicity, date of birth or approximate age, and relationship to the child(ren)

named in Section I) for each person believed to be responsible for the suspected abuse or neglect.

SECTION IV - ABUSE OR NEGLECT ALLEGATIONS

Describe the alleged abuse or neglect; how it affected the child (phys

ical injury; behavior exhibited by the child

due to the suspected abuse/neglect); and provide the date(s) the abuse or neglect occurred, if known.

Provide information on how you became aware of the suspected abuse or neglect.

Enter the name, address, telephone number and relationship of anyone who may have knowledge of the abuse or neglect or

the child’s/family’s

ituation. If the child(ren) received treatment or evaluation by a doctor or hospital due to the abuse or

neglect, provide identifying information on the doctor or hospital (if not the reporter).

SECTION V - OTHER PERTINENT INFORMATION

Enter any other information which may be helpful (e.g., prior abuse/neglect; name of child’s school; parents’ employment

or working hours; safety concerns for DHR staff who vis

it the child/family).

SECTION VI - REPORTER (Information is confidential and not released unless required by a court order)

You are requested to enter your name, address, telephone number and agency or relationship to the children identified in

Section I. Indicate whether you made a verbal (telephone or in-person) report to either the local Department of Human

Resources or a local law enforcement agency. If a verbal report was

made, identify the specific person, agency, and date the

report was made. Sign and date the form.

REFERENCES

1. Michels, Tricia M. 2000.“’Patients Like Us’: Pregnant and Parenting

Teens View the Health Care System. “Public Health Report 115:

557-575. Accessed November 13, 2015. http://www.ncbi.nlm.

2. Lane, Margo, Karen Garrett, Susan Millstein, Gail Bolan, and

Jonathan Ellen. 1999.“Features Pediatrics & Adolescent Medicine

153: 829-833.

3. CDC/National Center for Health Statistics Data: https://www.cdc.

gov/nchs/data/nvsr/nvsr67/nvsr67_01.pdf

4. Centers for Disease Control and Prevention. High School YRBS,

2015. https://nccd.cdc.gov/youthonline/app/Results.aspx?LID=AL

5. Simmons, Marlo, Janet Shalwitz, and S. Pollock. 2002.

Understanding Confidentiality and Minor Consent in California:

An Adolescent Provider Toolkit. San Francisco: Adolescent

Health Working Group, San Francisco Health Plan. Accessed

on November 13, 2015. http://lapublichealth.org/std/docs/

Adolescent_Confidentiality_Toolkit.pdf.

6. Centers for Disease Control and Prevention. 2015.“Vital Signs:

Trends in Use of Long-Acting Reversible Contraception Among

Teens Aged 15–19 Years Seeking Contraceptive Services—United

States, 2005–2013.”Morbidity and Mortality Weekly Report 64(13):

363-369. http://www.cdc.gov/mmwr/preview/mmwrhtml/

mm6413a6. htm?scid=mm6413a6_w.

7. Reddy, Diane M, Raymond Fleming, and Carolyne Swain.

2002.“Effect of Mandatory Parental Notification on Adolescent

Girls ‘Use of Sexual Health Care Services. “The Journal of

American Medical Association 288(6): 710-714. Accessed on

November 15, 2015. doi:10.1001/jama.288.6.710.

8. Ala. Code, § 22-8-4.

9. Ala. Code, §§ 22-8-4, -5.

10. 42 USC § 300(a); 42 CFR § 59.11.

11. 42 U.S.C. § 1396a(a)(7).

12. 42 U.S.C. § 1396d(a)(4)(c).

13. Ala. Code, §§ 22-8-4,-5,-6.

14. Ala. Code, §§ 22-8-4, -5.

15. Ala. Code, § 22-11A-19.

16. Ala. Code, § 22-11A-19.

17. Ala. Code, § 22-8-6.

18. Ala. Code, § 22-8-6

19. Gudeman, Rebecca, and Sara Madge. 2011.“The Federal Title

X Family Planning Program: Privacy and Access Rules for

Adolescents. “National Center for Youth Law Newsletter XXX.

Accessed November 13, 2015. http://youthlaw.org/publication/

the-federal-title-x-family-planning-program-privacy-and-

access-rules-for-adolescents1/.

20. Gowen, L. Kris. 2011.“How Mental Health Challenges Impact the

Sexual and Relational Health of Young Adults. “Sexual Health

Disparities Among Disenfranchised Youth 28-30. Accessed

on November 19, 2015. https://public.health.oregon.gov/

HealthyPeopleFamilies/Youth/ YouthSexualHealth/Documents/

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21. Shrier, L. A., S.K. Harris, M. Sternberg, and W.R. Beardslee. 2001.

22. Ramrakha, S., A. Caspi, N. Dickson, T.E. Moffitt, and C. Paul.

2000. “Psychiatric Disorders and Risky Sexual Behavior in

Young Adulthood: Cross Sectional Study in Birth Cohort.”British

Medical Journal 321: 263-266.

23. Centers for Disease Control and Prevention. 2013.“Youth

Risk Behavior Surveillance—United States, 2013.”Morbidity

and Mortality “Associations of Depression, Self-Esteem,

and Substance Use with Sexual Risk Among Adolescents.”

Preventive Medicine 33: 179-189. Weekly Report Surveillance

Summaries 63(4): 1-128. Accessed November 13, 2015.

24. Costello, E. Jane, Jian-ping He, Nancy A. Sampson, Ronald C.

Kessler, and Kathleen Ries Merikangas. 2014.“Services for

Adolescents with Psychiatric Disorders: 12-Month Data from the

National Comorbidity Survey-Adolescent.” Psychiatric Services

65(3): 359-366. Accessed on November 19, 2015. doi:10.1176/ appi.

ps.201100518.

25. Ala. Code, § 22-8-6. 42 C.F.R. § 2.1.

26. 42 C.F.R. § 59.5(a)(1).

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ClinicalServices. From Research to Practice. Accessed on

November 13,2015. http://www.advocatesforyouth.org/

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and Adolescents: Legal Questions and Clinical Challenges,

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journals/3608004.html

29. Ala. Code, § 22-11A-19.

30. 42 CFR § 5.11.

31. 42 U.S.C. § 1396a(a)(7).

32. 42 U.S.C. § 1396d(a)(4)(C).

33. 42 CFR § 2.14.

34. Advocates for Youth. Best Practices for Youth Friendly Clinical

Services. From Research to Practice. Accessed on November

13, 2015. http://www.advocatesforyouth.org/ publications/

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clinical-services.

Alabama Department of Public Health

P.O. Box 303017, Montgomery, AL 36130-3017

1-800-ALA-1818 • 8 a.m.-5 p.m.

alabamapublichealth.gov

ABOUT US

Alabama Child Health Improvement Alliance

Our mission is to improve health outcomes by fostering a culture of continuous quality improvement through

partnerships with practitioners, payers, families and organizations that deliver care to Alabama children.

• ACHIA supports pediatric and family medicine practices in improving the care delivered to infants, children and

adolescents.

• ACHIA supports practice-based improvement with faculty experts in targeted content areas, quality improvement

coaching to implement workflow changes, technical assistance in collecting and interpreting quality improvement

data, as well as information about coding the level of care delivered.

Alabama Department of Public Health

The mission of the Alabama Department of Public Health is to promote, protect, and improve the health of individuals and

communities of Alabama.

• The ADPH Family Planning Program promotes the well-being of families, responsible behavior, and healthy mothers and

babies. Our goal is to prevent unintended pregnancies through education and contraceptive services, allowing for the

planning and timing of pregnancies.

• There are 81 ADPH Family Planning-Title X clinics throughout Alabama offering family planning services. We provide

a wide range of confidential and professional family planning services to both females and males of all ages. These

services are provided regardless of age or income.

University of Alabama at Birmingham Leadership Education in Adolescent Health

• UAB LEAH is committed to improving the health status of adolescents, particularly those in the southeastern region

of the U.S. through its interdisciplinary leadership education of adolescent health professionals in a model center of

excellence in training, research and service that is adolescent-centered/family-involved, culturally competent, and

community-based.

• UAB LEAH is a Maternal and Child Health Bureau-funded training program. The information or content and conclusions

in this document are those of the authors and should not be construed as the official position or policy of, nor should

any endorsements be inferred by HRSA, HHS or the U.S. Government.