Counselling Consent Form

Counselling Consent Form

Please complete
Client Information
Full Name
Date of Birth

MonthDayYear
Age
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
Email
example@example.com
More Details About You
Are you currently taking any medication? If yes, then please list the medications and the reasons why are you taking them.
Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.?
Do you wear glasses or contact lenses?

YesNo
Emergency Contact Details
Primary Contact Number*
Secondary Contact Number*
Signature

Clear
Date Signed

MonthDayYear
CONSENT
The section below is to be completed by a parent or guardian who has completed this form for a minor (under 18 years); please sign the relevant section.
I am the parent or legal guardian of the Child named above and hereby grant permission for him or her to attend Ufuoma Obahor Surgery.

I acknowledge and understand that my Child's participation in the counselling sessions is voluntary, and my Child can withdraw at any time.
Parent or Guardian Name
Parent/Guardian Signature

Clear
Date Signed

MonthDayYear
Should be Empty:

Client Information