Consent to Treat a Minor

Consent to Treat a Minor
I, as the parent and/or legal guardian for the minor child give my consent for said child to receive counseling from a representative of Alba Wellness Incorporated. I understand that I may withdraw this consent at any time. I will first notify a representative of Alba Wellness Incorporated by telephone and then in writing, if and when I choose to withdraw this consent.
Parent/Guardian Name*

First NameLast Name
Name of Child/Minor*
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If applicable, please check type of custody arrangement:

Joint CustodySole Custody
By signing below, I agree that the above information is accurate to the best of my knowledge.
Parent/Guardian Signature*

Clear
Parent/Guardian Signature

Clear
Should be Empty: