Jose’ FreemanAgreement for Service / Informed Consent for Minors • January 18th, 2022
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Jose Freeman for the minor Child/ren
Stephanie Chase, LMFTAgreement for Service / Informed Consent for Minors • September 26th, 2022
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Stephanie Chase, MFT, for [name of the minor child(ren) herein “Patient”]:
AGREEMENT FOR SERVICE/INFORMED CONSENT FOR MINORSAgreement for Service/Informed Consent for Minors • November 15th, 2019
This Agreement has been created for the purpose of outlining the terms and conditions of services for the minor child(ren) [Client name] (herein referred to as “Client”) and is intended to provide [name of parent/legal guardian] (herein referred to as Representative) with important information regarding the practices, policies and procedures of ‘Lorelei O'Neill, Licensed Marriage & Family Professional Corporation (herein referred to as the “Office”), and the Therapist named above (herein referred to as the “Therapist”) and to clarify the terms of the professional therapeutic relationship between the Therapist and the Client. Any questions or concerns regarding the contents of this Agreement should be discussed with the Therapist prior to signing it.
VINDER LALLIAN, MA, LMFTAgreement for Service/Informed Consent for Minors • July 18th, 2016
This agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Vinder Lallian, LMFT, for the minor child(ren) and is intended to provide [name of parent(s)/legal guardian(s)] with important information regarding the practices, policies and procedures of Vinder Lallian, MFT and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed prior to signing it.
Frank A. Sanchez, Ph.D.Agreement for Service / Informed Consent for Minors • October 21st, 2021
(legal guardians of client herein “Representative(s)”) regarding the practices policies and procedures of Frank Sanchez, licensed marriage and family therapist, and to clarify the terms of the professional therapeutic relationship purpose of outlining the terms and conditions of services to be provided by Frank Sanchez (herein “Therapist”) for the minor child(ren)
TERRI J. CLARKEAgreement for Service / Informed Consent for Minors • February 20th, 2024
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Terri J. Clarke, LMFT. for the minor child: and is intended to provide [name of parent(s)/legal guardian(s)]
MFC51137)Agreement for Service / Informed Consent for Minors • February 28th, 2014
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Wendi Vecchiarelli, MA, LMFT, for the minor child
Real Life TherapyAgreement for Service / Informed Consent for Minors • May 10th, 2017
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Real Life Therapy and your Associated Therapist for the minor child(ren) (herein “Patient”) and is intended to provide [name of parent(s)/legal guardian(s)]
Cindy Berenstein-Sibley, LMFT Licensed Marriage and Family Therapist MFC # 46306Agreement for Service / Informed Consent for Minors • March 4th, 2021
Therapist generally requires the consent of both parents prior to providing any services to a minor child. If any question exists regarding the authority of Representative to give consent for psychotherapy, Therapist will require that Representative submit supporting legal documentation, such as a custody order, prior to the commencement of services.
MELANIE DAVIS, LCSWAgreement for Service / Informed Consent for Minors • July 2nd, 2014
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Melanie Davis, LCSW for the minor child(ren) (herein “Client”) and is intended to provide [name of parent(s)/legal guardian(s)] (herein “Representative(s)”) with important information regarding the practices, policies and procedures of Melanie Davis, LCSW (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
CA Licensed Marriage and Family Therapist www.lanagarvin.comAgreement for Service/Informed Consent for Minors • July 10th, 2016
This agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Lana Garvin, LMFT, for the minor child(ren) and is intended to provide [name of parent(s)/legal guardian(s)] with important information regarding the practices and procedures of Lana Garvin, LMFT, and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORSAgreement for Service / Informed Consent for Minors • October 5th, 2016
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Christopher M. Mayer, LMFT for minors (persons 14-17 years of age) seeking therapeutic treatment on their own accord. Therapists generally require the consent of both parents / legal guardians prior to providing any services to a minor or child. However, it is also understood that on occasion minors who are 14-17 years of age may seek treatment on their own for various reasons, and hold the legal right to do so without the consent of their parent(s)/guardian(s). This form is for minors who are consenting to their own treatment under such circumstances. All clients will be asked for proof of their age (two forms of ID are required and one must be a photo ID).
AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORSAgreement for Service / Informed Consent for Minors • April 18th, 2019
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Yvonne Miller, LMFT for the minor child(ren
Agreement for Service / Informed Consent for MinorsAgreement for Service / Informed Consent for Minors • February 16th, 2019
Quiet Waters CounselingAgreement for Service / Informed Consent for Minors • May 6th, 2015
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Joy Wong Liu, MFT for the minor child(ren)
AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORSAgreement for Service / Informed Consent for Minors • May 19th, 2015
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Michele Sherman, MFT for the minor child(ren)
AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORSAgreement for Service / Informed Consent for Minors • March 16th, 2013
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Kim Jensen, MA LMFT for the minor children (herein “Patient”)
AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORSAgreement for Service / Informed Consent for Minors • February 4th, 2022
This Agreement has been created for the purpose of outlining the terms and conditions of services and is intended to provide”) with important information regarding the practices, polices and procedures of David Barry (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.
41715 Enterprise Circle N #102, Temecula, CA 92590Agreement for Service / Informed Consent for Minors • September 13th, 2021
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by the Sigil Social Foundation(herein “Therapist”), for the minor child(ren)
Michelle K. KennedyAgreement for Service / Informed Consent for Minors • September 25th, 2021
This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Michelle Kathleen Kennedy, LMFT for the minor child:
