Signature Sheet — Child/Adolescent Form

I have received the Client Guide containing important written information that will help me understand the counseling process for my child/adolescent including: Informed Consent, a Description of Therapy, Benefits and Risks of Therapy, Confidentiality Issues, Fee Information, Client Rights and Responsibilities and the Notice of Privacy Practices.

I hereby give my consent for treatment, which authorizes SpringHaven, Inc. to evaluate and/or treat the minor named below. Treatment means provision, coordination, or management of clinical/counseling care and related services by one or more providers. I/we understand that we have the right to control the disclosure of private counseling information about my/our child. However, in the interest of resolving the issues I/we have brought to the counselor, I/we give the counselor permission to reveal or withhold information to/from us or others that in the counselor's judgment is necessary to best help and protect my/our child.

I consent to allow SpringHaven, Inc. to use or disclose my protected health information to any and/or all of the following that may apply to me: Insurance Company, Employee Assistance Program, Amish Church Fund, Church Partnership Program and Non-profit Ministries for payment purposes. Payment means the activities undertaken by SpringHaven, Inc. to obtain reimbursement for the provision of counseling services. I authorize any of the above to make payment directly to SpringHaven, Inc. for services rendered.

Based on the information received in the Client Guide, I refuse to consent to treatment for the client named below.