Adolescent Counseling Consent Form
Adolescent Information
Full Name
Date of Birth
Age
Home Address
Parent/Guardian Information
Parent/Guardian Name
Relationship to Adolescent
Phone Number
Email Address
Consent for Counseling
I give my consent for the above-named adolescent to participate in counseling services.
Additional Details or Limitations
Confidentiality
Risks and Benefits
Parent/Guardian Signature
Printed Name
Date
Adolescent Acknowledgement (Optional)
I understand and agree to participate in counseling as described above.
Adolescent's Printed Name
Date