Parental Approval of Therapy & Safe Harbor Agreement

1

Are you a parent or legal guardian of the child?

Yes

No

2

Since you indicated you are not a parent or legal guardian of the minor, you cannot complete this form. Please have their parent or legal guardian complete the form or contact us with any questions at (715) 832-1678.

3

Is there another parent or legal guardian of the child?

Yes

No

4

Is the other parent able to sign right now?

Yes

No

5

You may move forward with signing but note that the other parent must also sign this form before treatment can occur. If you have any questions, please call us at (715) 832-1678.

6

Your Name* This field is required.

First Name

Last Name

7

Your Signature* This field is required.By signing, you acknowledge you have read and understand the CCC Parental Approval for Therapy and Safe Harbor Agreement.

Clear

8

Your Phone Number* This field is required.

9

Your Email* This field is required.

example@example.com

10

Name of the other parent or legal guardian* This field is required.

First Name

Last Name

11

Signature of the other parent or legal guardian* This field is required.By signing, you acknowledge you have read and understand the CCC Parental Approval for Therapy and Safe Harbor Agreement.

Clear

12

Name of Child/Adolescent:* This field is required.

First Name

Last Name

13

Child Date of Birth:* This field is required.