Parental/Guardian Consent

Client's name:

Date of Birth:

Insurance ID #:

Insurance Company:

Client's Social Security #:

I hereby authorize: INTEGRATED THERAPIES PLLC to provide counseling to a minor under my guardianship:

Print Name of the Minor

I authorize INTEGRATED THERAPIES PLLC to charge me directly for counseling services:

Enter your initials

I agree to remain actively involved with my child’s health and well being and commit to meeting with INTEGRATED THERAPIES PLLC a minimum of once a month for the purpose of collaboration and promotion of family wellness:

Enter your initials

Please state any areas of special concerns:

Parent / Guardian Signature

Date of Signature:

Print Name

Date of Signature:

Integrated Therapies Representative Signature

Date of Signature:

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