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.
______ Individual counselling/assessment
______ Family/couple counselling
______ Play therapy
______ Educational assessment
______ Other (specify)
Signed: __________________________ Date:
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.