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: CAPTCHA Δ
