Consent To Treat A Minor | Anat Fein | Therapist in Cupertino

Anat Fein, MA LMFT
21760 Stevens Creek Blvd., Suite 202
Cupertino, CA 95014
(408)-310-0800
[email protected]

I hereby acknowledge that I am the parent/legal guardian of the below named minor child, and do consent to the provisions of counseling services to the child with Anat Fein, MFT.

Name*

Are you a parent or a legal guardian of the patient?*

Parent
Legal Guardian

Are you separated or divorced from the patient's other parent?*

Yes
No

Is there a court order or agreement that states both parents must give permission for this treatment?*

Yes
No

Please initial here if there is NO court order or agreement that states both parents must give permission for this treatment.*

Please initial here if there IS a court order or agreement and both parents’ signatures are required. (Please provide the court order before therapy begins)*

Name of Minor Child*

Name of Parent or Legal Guardian*

Parent or Legal Guardian's Signature*

Date*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country