Consent for Intervention

 (NOTE: Page is Formatted the same as our Hard Copy Sheet except for Online Submit Option)

 

(A) Adolescent over 16 years of age/Adult

 

I agree to be an active partner in the therapy recommended by and discussed with (counsellor):____________________________________.  I know I am free to revoke my consent at any time.

 

Therapy:

______ Individual counselling/assessment

 

______ Family/couple counselling

 

______ Play therapy

 

______ Educational assessment

 

______ Other (specify)

 

Signed: __________________________ Date:

Signed: __________________________Date:

 

(B)Guardian

 

I give permission for (Name of Child or adolescent) __________________________ to take part in the therapy recommended by and discussed with  (Counsellor): _____________________

 

I know I am free to revoke my consent at any time.

 

 

By clicking SUBMIT below I am giving my Consent for Intervention. I realize I can revoke this consent at any time.

• Client/Guardian Name: *

• 2nd Client/Guardian Name:

• Session Date: *

 

(Rev. 06.17)