Permission to Treat a Minor

I,                            (parent/guardian)    give my permission to                    (counselor)

 to see my son/daughter,                   (child), date of birth                            ,

for treatment with or without me being present in the same session. I/We understand that

the counselor is the holder of confidential and privileged information. In the best interest of developing a trust relationship between the counselor and my child(ren), I/we give the counselor permission to reveal/withhold information that in his/her clinical judgment is necessary to best help and protect my child(ren). The only exceptions in the discretion would be in the case of:

client is being harmed by someone, there is a risk of suicide, there are threats to harm someone else and/or to do harm to someone else’s property.

Parent//Guardian Signature                                                  Date      

Counselor/Witness Signature                                               Date