Consent for Counseling Services to child(ren)

Consent for Counseling Services to child(ren)

In order for minor children to receive counseling services, it is necessary for the parent or legal guardian to grant permission for such services to occur.
Name and dates of birth of child(ren) to receive counseling service:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name of person requesting services:

First NameLast Name
Your relationship to the child(ren)
Are you the legal parent or custodian of the above named children?

YesNo
I hereby swear that I have a legal right to obtain treatment for the above named children

YesNo
In instances of divorced parents, a stepparent, a grandparent, a guardian, or other, you may be asked to provide a copy of the court order which names you the legal custodian of the above children. Are you willing to do so?

YesNo
If the answer to any of the above questions is “NO” counseling services cannot be provided to the above-named child(ren) until a copy of the court order which names you the legal custodian is provided to this office.
I, your name , consent to blankof Type a label to provide counseling services to the child(ren) named above. These services may include: clinical interviews of the child(ren), testing of the child.
Name of person filling out this form

First NameLast Name
Should be Empty: