Child Counseling Parental Consent Form
Child Information
Full Name
Date of Birth
Address
Parent/Guardian Information
Full Name
Relationship to Child
Phone Number
Email
Consent
Purpose of Counseling
Relevant Medical or Mental Health History
I give consent for my child to participate in counseling services.
I understand the limits of confidentiality explained to me.
Signatures
Parent/Guardian Signature
Date
Counselor Signature
Date