Parental Consent for Counselling

First Name *

Last Name *

Visit Date *

Parental Consent for Counselling

Your therapist wants to ensure that both parents, who have parental authority of the child, be informed of the counselling given to their child(ren). Both parents need to agree to counselling services for their child or she will not be able to provide services to them. Your therapist will inform the client of confidentiality and privacy (see the privacy and related policies form), and will request verbal consent. If one of the parents who have parental authority refuses or chooses not to continue the services, Your therapist will have to cease service with the child. Your therapist wants to ensure that both parents, who have parental authority of the child, be informed of the counselling given to their child(ren). Both parents need to agree to counselling services for their child or she will not be able to provide services to them. If one of the parents who have parental authority refuses or chooses not to continue the services, your therapist will have to cease service with the child. After reading the information in this consent for, please type in the name of the parent(s) of the following child(ren), allowing your therapist to provide counselling to your child(ren). *

Child(ren) Information

Please include the child(ren)'s name, and date of birth. *

I commit myself to inform the other parent, who has legal authority of the child(ren), of counselling services given to the child(ren) and the procedures to take if they no longer agree with counselling services. Please choose the 'yes' option to acknowledge that you read, understand, and will follow through.

NoYesNo

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

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Parental Consent for Counselling

Thanks for completing the form.

The information has been received.

Thanks for completing the form.

The information has been received.

Parental Consent for Counselling

Child(ren) Information

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