Clinical - Children's Counseling Permission

Clinical - Children's Counseling Permission
Parent/Guardian's Full Name*
Child's Full Name*
I authorize that my minor child may receive counseling and related services at SARC (Sexual Assault/Spouse Abuse Resource Center).
Custody

Not applicableNo custody agreementI have sole legal custodyJoint legal custody - I have spoken with my child’s other parent concerning our child receiving counseling services at SARC.
*** According to Maryland Health-General Code § “A minor 16 years old or older can consent to treatment of a mental or emotional disorder by a physician or psychologist, but cannot refuse such treatment when a parent or guardian has given consent.”
Parent/Guardian/Client Signature and Date

Clear
Should be Empty: