Children's Center - Informed Consent for Treatment

Informed Consent for Treatment
I voluntarily agree to give consent for treatment by The Children's Center for Psychiatry, Psychology and Related Services for myself and/or my family members.
Name of Patient

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Print Name

First NameLast Name
If applicable, relationship to Child/Patient
Should be Empty: