Treatment of a Minor

Turning Point Counseling

Consent for Treatment of Minor
(Please print this form, complete, sign, and fax to 714-367-2171)

Name of Minor: ______________________________________

Date of Birth of Minor: _________________________________

Counselor’s Name:_____________________________________

This is to certify that I give permission to Turning Point Counseling and the Counselor listed above for treatment of my child.

This treatment may include individual, group psychotherapy and testing. This treatment may include consultations with other Turning Point Counseling Associates including Psychologists, MFCC Interns, Career Counselors, or Nutritionists.

California State law mandates the reporting of certain types of child abuse, including physical abuse, sexual abuse, unlawful sexual intercourse, neglect, emotional and psychological abuse. All actual or suspected acts of child abuse will need to be reported to the appropriate agency.

This treatment may also include referral to other appropriate State and County agencies for further counseling.

Signature of Parent/Guardian: _______________ Date: ________

Printed Name of Parent/Guardian: _____________ Witness/Title: ____________

Street Address: _____________________________________________

City: __________________________ State: ____ Zip Code: ____________

Hm. Phone Number: (__) ___-_____ Wk. Phone Number: (__) ___-_______

Turning Point Counseling

14943 Desman Road • La Mirada • California 90638 • 800-998-6329