Telehealth Consent Form for Youth Counseling

Client Information

Name of Youth: Date of Birth: Parent/Guardian Name: Parent/Guardian Email: Parent/Guardian Phone:

Telehealth Counseling Overview

Risks and Benefits

Confidentiality

Emergencies and Safety

Parent/Guardian Consent

I have read and understood the information provided above. I consent to my child participating in telehealth counseling.

Parent/Guardian Signature: Date: