Advanced Behavioral Health Counseling

Specializing in Group, Individual, Coaching and Marital Therapy

Minors Consent Form

Consent for Treatment of Minor



I __________________________________________ allow my child/teen

_______________________________________to receive

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.

Parent: _____________________________________________

Date: ______________________________

Parent: _____________________________________________

Date: ______________________________

Minor ______________________________________________

Date: _____________________________