Minor in Treatment

Minor in Treatment

Guardian Consent for 16-17 year old at session with no parent
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Teri's Health Services allows for 16 and 17 year old minor clients to come to the therapy session without guardian present when at least one guardian consents to this. Guardian understands that during the timeframe of the appointment guardian is to stay available if needed. Guardian may be called by front office or counselor if questions come up.

At intake and treatment planning sessions Guardian may be asked to be present during this time. The counselor will advise when these dates occur.

This agreement includes telehealth visits as well.
Guardian Name

First NameLast Name
Relationship to Client
Guardian Consents to Minor child being in treatment on their own without guardian present (telehealth and in person)

YesNo
Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty: