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Parental Permission to Treat a Minor

Kanawha Pastoral Counseling Center

Client Name: ___________________________

16 Leon Sullivan Way, Suite 300

Charleston, WV 25301

Date: __________________________

304-346-9689

I hereby give permission for (child’s name) _______________________________________

my (child, ward, etc.) _____________________, who is _____ years old, for counseling at KPCC.

1. I hereby verify that I have the legal right to bring this child for counseling. Initial: ______

2. If child’s parents live separately, or are divorced, I verify that I have sole/joint (circle) decision

making responsibility for my child’s emotional/mental/medical health care. Initial: ______

3. If the court order does not specify sole responsibility for regular (non-emergency) medical

treatment, this form must be signed by both parents.

4. I understand that the therapist will likely contact both parents to gather information and to

discuss treatment options.

5. I understand that all consultation between the above-named child/client and the therapist shall

be held in strictest confidence. I will not ask the child/client or the therapist to divulge the

contents of their conversations.

6. I may ask to be included in a joint session with the therapist and the child/client if I have any

concerns which I wish to share with either of them.

7. I may also ask to meet individually with the therapist to discuss issues related to my parenting

of my child.

8. Anything I choose to share with the therapist about the child/client by phone or otherwise may

be communicated to the child/client by the therapist.

9. I understand that if the child/client poses a threat to the physical well-being of him/herself or

others the therapist will inform me of the danger. I understand that if the therapist has a reason

to suspect neglect or abuse of my child, the therapist is obligated to report this to Child

Protective Services.

_______________________________________ __________________ ____/____/____

Signature of Mother or Guardian 1

Phone

Date

_______________________________________ __________________ ____/____/____

Signature of Father or Guardian 2

Phone

Date

Parental Permission To Treat A Minor