Parental Consent for Child Counseling
Child Information
Child's Full Name
Date of Birth
Parent/Guardian Information
Parent/Guardian Name
Relationship to Child
Contact Number
Counseling Provider
Provider/Agency Name
Counselor's Name (if known)
Consent
I hereby authorize the above-named provider and counselor to provide counseling services to my child named above. I understand the purpose and nature of counseling, and give my consent for participation.
Additional Notes (Optional)
Parent/Guardian Signature
Date
Counselor's Signature
Date