Karen E. Engebretsen, Psy.D., LLC.

DABPS, DNBAE, FACAPP, FAAIM, DAPA, CDVC, DAC, CHT, CST

Licensed Psychologist, FL Lic: PY5409

 

 

 Consent to Mental Health Treatment of a Minor

 

 I, __________________________________________, do hereby state that I am the

                     (Name of parent or legal guardian)

 biological parent or legal guardian, having custody of __________________________________,

                                                                                                         (Name of minor)

age ________         Date of birth _____/_____/_____,           who resides with me at

 

_____________________________________________________________________________                                               (street address, city, state, zip code)

 I hereby give my consent to Karen E. Engebretsen, Psy.D., LLC. to provide mental health

 

treatment to ___________________________________________________________________

                                                     (Name of minor)

 on an ongoing basis and in an emergency when needed.

                                                                              ______________________________________

                                                                                               (Parent or Guardian)

                                                                              ______________________________________

                                                                                                       Date   

 Witness: ___________________________________________

 

 Date: ______________________________________________