Parent/Guardian Consent and Custody Form (For Clients Under 18)

Parent/Guardian Consent and Custody Form (For Clients Under 18)

Provide consent and details regarding child custody arrangements (if parents/guardians are separated or divorced). Some custody agreements require consent from both parents/guardians.
Photo ID

Please upload a clear scan or photo of your ID.
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Child's Full Name

First NameLast Name
Parent/Guardian Full Name

First NameLast Name
Relationship to Child
Custody Details
Upload Custody Agreement if Applicable

Clear scans or photos are accepted.
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Parent/Guardian Disclosure

Confidentiality for Clients Under 18

Counseling works best when your child feels safe being honest. For that reason, I ask parents and guardians to understand and respect a reasonable level of privacy for their child in therapy.

What I share with you. As the parent or legal guardian, you have a legal right to information about your child's treatment. In general, I'll share:

* whether your child is attending
*general progress and treatment goals
*recommendations for supporting your child at home

I usually don't share the specific details of what your child talks about in session unless your child agrees, or I believe it's important for their wellbeing. If you ask for your child's records, Texas law allows me to withhold portions if I believe releasing them would be harmful to your child's physical, mental, or emotional health.
I understand the above policy regarding confidentiality for my child
Date of Consent

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Custody & Court Involvement Policy
Ardent Grace Counseling does not provide therapy to minors when a custody, conservatorship, or visitation dispute is pending, being considered, or likely. A complete, current, judge-signed copy of any custody order or decree naming your child must be uploaded before the first session, and each parent with the right to consent to treatment must sign. Your therapist is a treating therapist, not a custody evaluator, and will not write letters or give opinions to a court or attorney about custody or either parent.

By signing, you agree not to subpoena the therapist or her records in any custody, divorce, or family-law matter. If she is required to take part in a legal matter, reasonable fees apply, and the signing parent(s) are responsible for them.

Read the full policy here:

https://www.ardentgracecounseling.com/custody-policy/
I have read and understand the Custody & Court Involvement Policy
No custody dispute involving this child is pending or being considered.
I agree not to subpoena the therapist or her records, and I understand reasonable fees apply if she is required to participate in any legal matter
Signature of Parent/Guardian
Date of Consent

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: