PERMISSION TO TREAT: As legal guardian for   First Name   Last Name.  I understand that my   child   self      will be taking part in mental health services which are psychological in nature. I have received a copy of the Notice of Privacy Practice and Informed Consent and hereby give permission for K&G Counseling and Consultation to provide services to my   child   self      .

FREEDOM OF CHOICE: As a legal guardian for   First Name   Last Name   , I understand that the choice of providers is my responsibility and right as the   client   parent   guardian         . I further understand that I have the right to contact the providers prior to selection so that I may determine the best provider for my   child   self      . I also understand that I may at any time choose another provider for this service by notifying my current provider.

As legal guardian for   First Name   Last Name   , I agree that this member is not receiving concurrent TCM services from another source; member is not required to receive TCM services as a condition of care; and TCM has not provided other services to member.