Consent To Treat A Minor

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*
Date Format: MM slash DD slash YYYY
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country