Consent to Treat Form

Connected Crew, LLC - Consent to Treat

Client Name

Date of Birth

Date

ParentGuardian Name

Relationship to Client

Connected Crew is a nonprofit organization that provides therapeutic services to youth and families in high-risk and underserved communities. Our services include mental health assessments, counseling, and related support services.

By signing this form, I give consent for Connected Crew and its authorized staff to provide therapeutic and supportive services to the above-named child. I understand the nature and purpose of these services and have had the opportunity to ask questions.

I understand that participation in services is voluntary and may be withdrawn at any time. I understand that information shared during sessions will be kept confidential except where required by law e.g., risk of harm to self or others, abuse, court order I understand that my child's records may be used for treatment planning and service coordination.Consent Acknowledgements:

Signature of Parent/Guardian: Date:

Signature of ParentGuardian

Date