do hereby request of and grand permission to the Children's Advocacy Center (CAC) Serving Bastrop, Lee and Fayette Counties to provide mental health services to the above-named client in order to assist in the promotion and maintenance of improved emotional, social and behavioral functioning. I understand that this service may include methods of assessment, evaluation and counseling generally used by the mental health professions.
It is understood that CAC Staff will make appropriate referrals for services needed beyond those listed above. I also understand that my child's Therapist, in the course of providing assessment and/or counseling services, may seek consultation when necessary. Consultation will be restricted to the Therapist's professional supervisor and/or staff supervision. I understand that like confidentiality laws also bind my child's Therapist, supervisors, and consultants.
I also agree and understand that my child and her/his safety is my responsibility while we are at the CAC and not in the therapy session with the Therapist.
I assert that I am this child's parent and/or legal guardian and have the legal right to give permission for these services.