Consent for Treatment of a Minor

This form must be completed by a parent or legal guardian to authorize counseling services for a minor (under 18).

Minor's Information

Minor's Full Name * Required

Minor's Date of Birth * Required

Minor's Current Age * Required

Parent / Legal Guardian Information

Parent / Legal Guardian Full Name * Required

Relationship to the Minor * Required

Biological parentAdoptive parentStepparentCourt-appointed legal guardianFoster parentOther

Parent / Guardian Phone Number * Required

Parent / Guardian Email Address * Required

Custody and Legal Authorization

Custody arrangement for this minor: * Required

Both parents share legal custodyI have sole legal custodyPrimary physical, shared legal custodyOther arrangement

If 'Other', please describe. If shared, does the other parent consent to treatment? Optional

Are there court orders affecting your ability to authorize treatment? * Required

Yes No

If yes, please describe relevant court orders: Optional

Confidentiality for Minors

Building trust is essential for effective therapy with minors. While parents have legal rights, some degree of session privacy is maintained.

Your therapist will provide general progress updates and clinical recommendations to the parent/guardian.

Confidentiality will be broken if the minor reports danger to self or others, abuse, neglect, or other safety concerns.

The balance of parental access and the minor's privacy will be discussed during intake and may be adjusted over time.

I understand and agree to the minor confidentiality approach described above. * Required

Yes No

Parental Involvement

I would like to be involved in treatment through: Optional

Regular progress updatesOccasional joint (parent-child) sessionsParent-only sessions for treatment strategiesGuidance on supporting my child between sessionsCollateral contact with school or pediatrician

Other Parent / Guardian Contact

Other Parent / Guardian Name (if applicable) Optional

Other Parent / Guardian Phone Number Optional

May the therapist share treatment info with the other parent? Optional

YesNoLimited info only (general progress)Not applicable

Authorization and Consent

I authorize counseling/psychotherapy for the minor named above. * Required

Yes No

I confirm legal authority to consent to treatment for this minor. * Required

Yes No

Parent / Legal Guardian Signature * Required

Signature

I confirm that I have legal authority to consent to treatment for the minor named above and authorize counseling services.

Consent for Treatment of a Minor

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