Parental Consent Form


The Counseling Center has been contacted to schedule an Intake/Assessment appointment for (please fill in your child’s name & DOB):


Relationship to Patient: *
I give my consent for my child to receive the following treatment:                               *


Please sign below.


The following is The Counseling Center’s Policies with respect to treatment of children and adolescents whose parents who are divorced. While many divorces are amicable with parents working collaboratively for the good of the children, others may be contentious. While in many cases the issues discussed here may never arise, we have found it beneficial to make everyone aware of the policies and protocols of The Counseling Center with respect to treatment of children and adolescents whose parents who are divorced. The following are guidelines and understandings we need to have with you in order to provide the best possible care for your child or family. For us to schedule your child for counseling, and/or a medication evaluation, we require that the attached consent be signed by each parent to indicate review and acceptance.

 

Please carefully read and initial the following to verify your understanding of our policies

I understand that my typed initials shall have the same legal and binding authority as my handwritten initials.