All children and teens under the age of 18 years must be accompanied by a parent or guardian to their visits and must review this form together to the degree that it is age appropriate. The form is designed to be completed primarily by the parent/guardian.

I, below named adult (#1), attest that I am the custodial parent or guardian of below named minor (#2), and I authorize my child/teen to participate in therapy at Maria Droste Counseling Services. I agree and understand that while insurance may be billed for psychotherapy services, I am legally responsible for any and all charges incurred in providing this and/or other services by this office. Copies of documentation of legal custody of your child/teen, and any other legal issues pertaining to the child/teen must be provided on or before date of first visit. Copies of these documents will be kept on record.

PLEASE READ: Maria Droste Counseling Services (MDCS) uses your information for our internal statistics to help shape our future programming. Any and all data used will remain completely anonymous. We will never share you or your child’s information with any third parties unless requested by you and in compliance with our policies.

We do share aggregate summaries with others for the purposes of outreach and improving our services, which does not include your individual responses to any questions or any identifiable information about you. For example, we may share a statistic such as the following: 56% of clients are female.

Please speak with your therapist if you have any questions or concerns about this statement.