Testimonials

Minor Consent Waiver

Clients under the age of 18 must have this form completed by their parent or guardian.

Parent/Guardian Full Name

Minors Full Name

Minor's Date of Birth

Please specify anything we should know about - Type N/A if not applicable

Initials of Parent/Guardian

I declare that the info I’ve provided is accurate & complete

By initaling below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You understand that you are required to accompany the minor, unless you as the parent/guardian authorize us to treat the minor with out you or another authorized adult present. You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor. You also agree that you have completed the section above and have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).

Thanks for submitting!

Minor Consent Waiver

** Clients under the age of 18 must have this form completed by their parent or guardian. **

Clients under the age of 18 must have this form completed by their parent or guardian.