Adolescent Counseling Consent Form

Adolescent Information

Full Name

Date of Birth

Address

Parent/Guardian Information

Full Name

Relationship to Adolescent

Phone Number

Consent

I understand the purpose and nature of counseling for my child. I acknowledge the potential risks and benefits, and have been informed of confidentiality and its limits.

I voluntarily give consent for counseling services for the above-named adolescent.

Confidentiality

Information shared in counseling sessions will be kept confidential unless required by law to disclose or for the safety of the adolescent or others.

Parent/Guardian Signature Date

Adolescent Signature Date

Counselor/Witness Signature Date