Family Counseling Consent Form
Family Information
Family Name
Address
Phone Number
Email
Family Members Attending
Member 1 (Name & Relationship)
Member 2 (Name & Relationship)
Member 3 (Name & Relationship)
Member 4 (Name & Relationship)
Purpose of Counseling
Please briefly describe the main concerns or reasons for seeking family counseling:
Confidentiality Agreement
I understand that information shared in counseling sessions is confidential and will not be disclosed without explicit consent from all participating members, except where required by law.
Consent
I have read and understood the information provided above. I consent to participate in family counseling.
Signatures
Signature (Member 1)
Date
Signature (Member 2)
Date
Signature (Member 3)
Date
Signature (Member 4)
Date