Consent for Treatment of Minor
I __________________________________________ allow my child/teen
psychotherapeutic counseling sessions by Sylvia Ybarra, Marriage and
Family Therapist, which includes psychotherapeutic assessment, treatment
and referral. This treatment may be conducted in an individual, conjoint or
family therapy session as deemed most appropriate by the therapist.
I may call to be informed of my child/teen's progress in treatment at any
time and/or make an appointment to meet with the therapist to review my
child's progress. I agree to pay for any time of consultation be it in person, email or phone at the agreed upon hourly rate.
I am responsible for payment of all treatment except where other
arrangements have been made. In the case of treatment being denied for
payment, I will take full responsibility to pay the amount due.