Permission for outpatient mental health treatment of a minor child
Please read and sign this from before your child sees a clinician at The Wellness Room
I/We give permission to The Wellness Room LLC Staff to access and treat (please sign below) *
Your answer
Client Name *
Your answer
Client DOB *
Your answer
Signature of Parent/Legal Guardian *
Your answer
Signature of Parent/Legal Guardian (if applicable)
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy