Child Intake Form (Page 8 of 8) in pdf

Child Intake Form Page 8

Client Name: ___________________________________________________________ Date: ___________________

Parent or Legal Guardian Responsibility/Consent:

You, the parent, are a full partner in counseling. Your honesty and effort is essential to success. You are responsible to

attend parent sessions as deemed necessary by your child’s therapist. If, as we work together you have suggestions or

concerns about your child’s counseling, I encourage you to share these with me so that we can make the necessary

adjustments. Your child’s therapist sees you, the parent, as part of therapeutic change,and without you change will not

be as successful; therefore your child’s therapist will give suggestions, advice, or homework in order to help your child

meet their counseling goals both inside and outside the counseling session. You, the parent, are considered a client of

West Houston Counseling Center. Thereby all above information on confidentiality, rights, fees, referrals, effects,

applies.

I have read and I understand the above information: _____________________________________________________

Parent Signature

Date

Child Intake Form Page 8