Minor Treatment Release

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Fields marked with an * are required

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

,hereby give my permission

For the provision of counseling services to

Minor First Name

Minor Last Name

Minor Birthdate

, a minor child, for whom I am the custodial parent, managing conservator, or legal guardian.

Proof of custody or guardianship will be required to initiate counseling services for a minor child (under age 18). This proof may take the form of a finalized divorce decree, legal guardianship paperwork, or other validation of an adult's right to consent to mental health treatment for a minor child. We will make a photocopy of this information for the minor client file.

Parent/Guardian Signature *

Today's Date

We're Glad You're Here!