Parental Consent Form

Thank you for trusting O’Leary Counseling to assist you with your personal concerns. Please take the time to read and understand this document and ask me about any portion which may be unclear to you.

O’Leary Counseling, LLC will provide psychotherapy services to your child. The goal is to help your child be successful emotionally, socially and academically. Individual, couple and family counseling is available to enhance your child success. I am requesting your involvement, and need permission to see your child.

Child Name

This consent is valid until termination of the therapeutic relationship. You have the right to revoke consent at any time. Verbal or written notification will be accepted. I understand the information stated in this form and give consent for my child to receive therapeutic counseling with O’Leary Counseling, LLC.

Child First Name

Child Last Name

Parent's Signature

Date

Parent's Name

Relationship

Home Phone

OK to leave message?

Work Phone

OK to leave message?

Home Address

State, Zip

Email Address

Date

Parent's Signature

Parent's Name

Relationship

Home Phone

OK to leave message?

Work Phone

OK to leave message?

Home Address

State, Zip

Email Address

Date

Please list all persons who are authorized to pick up child from a therapy appointment. First and Last name. Children will not be released to unauthorized persons.

If child’s parents are legally separated or divorced, please complete the following*:

Legal Custody (%):

Guardian 1 (%)

Guardian 2 (%)

Physical Custody (%):

Guardian 1 (%)

Guardian 2 (%)

*Please provide a copy of the custody agreement.

Confidentiality

For therapy to be effective, confidentiality must be honored. No information will be shared with a party outside of the office without your written consent. Additionally, information your child shares with their
therapist in his/her private sessions will be held confidential. However, the goals and progress of the
counseling may be shared with you, any other legal custodial parent or guardian. By law, confidentiality
must be breached if a therapist or therapist intern suspects that any minor is being or has been abused, if a person plans to physically harm another person, or if a person plans to harm him/herself. Additionally,
breaching of confidentiality will occur if a therapist or therapist intern hears that an elder or dependent
adult is being or has been abused.