Parent/Guardian Consent

This form is required

for clients under the age of 18.

In order to complete this form

you must be the Parent/Guardian of

the Minor client named.

Minor's Full Name*

Minor's Date of Birth*

Parent/Guardian's Full Name*

Parent/Guardian's relationship to the minor*

Parent/Guardian's phone number*

Parent/Guardian's email address*

I verify that I am the person named herein as the Parent/Guardian for the minor listed, that I am over the age of 18, and that I have the legal authority to sign this form. I have read, understand and agree to the Appointment and Payment Policies (effective 10/13/2022), and I consent to allow treatment and services to be provided by Marney DeFoore, LCSW-S to my minor child listed in this form. I agree to receive account management and appointment scheduling information by phone, voicemail, text, email or US Mail (message and data rates may apply). I understand these terms are subject to change.

Marney DeFoore LCSW-S

Parent/Guardian Consent

This form is required

for clients under the age of 18.

In order to complete this form

you must be the Parent/Guardian of

the Minor client named.