Minor Release Form
All persons under the age of 18 are required to have a parent or guardian fill out this form.
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By signing below you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our clinic. You understand that you are required to remain at the facility for the entirety of the minor's treatment(s). You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor.  You also agree that you have completed the intake form and have informed the practitioner of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).  I understand the scope of practice by the practitioner it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care. I permit my minor child to receive treatment(s) at this clinic and agree to all the above terms. 
Child's Name: *
Child Age: *
Parent or legal guardian Name: *
Date *
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