This is a my consent as the parent-guardian of the above listed minor that I give Pain to Performance PLLC/Pain to Performance Solutions dba and Alexis E. Kurtzman the attending therapist my permission to work on my child who is less then 18 years of age. I understand the RCW 26.28.015 rule-law is that a minor must have a legal parent or guardian present the whole time in the clinic room unless they are over 14 years of age. PTPS policey is that a parent/guardian must be in the room the whole time if the minor patient is under the age of 16. This form is an addendum to the basic new patient health history form that my minor will be filling out with my help depending on age. My signature below is my consent and agreement to these policies ad RCW rules-laws.