Twin Oaks Counseling
Consent for Treatment of a Minor



I, _________________________________________, give my consent to ____________________________
                                 Name of parent or legal guardian                                                                                                                       Name of counselor

to see my son or daughter, ________________________________ for counseling with or without my being present


during the session.



I/we understand that we have a right to control the disclosure of private counseling information about my child.  However, in the interest of resolving the issues I/we have brought to the counselor, I/we give the counselor permission to reveal or withhold information to/from us or others that in the counselor's judgment is necessary to best help and protect my/our child.

Exceptions to this discretion include, but may not be limited to:
1.)  A client's indication of bodily harm to self or others.
2.)  Involvement in a felony.
3.)  Suidical intentions.
4.)  Reasonable evidence of child abuse or neglect.


______________________________________     
Signature of Parent/Legal Guardian Signature  

__________________________________                                                                                     
Date

______________________________________    
Print Name


__________________________________________________     
Signature of Counselor    


_______________________________________________                                                                                                                                                     
Date

1230 Big Bend Road, Ballwin, Missouri, 63021
636-861-1870