Tia Harms LLC Counseling for Individuals, Couples, or Groups

Ph. 503.559.2233 tiaharms@hotmail.com

Parental Consent to Therapy of a Minor

I, ________________________, parent or legal guardian of, ________________________, hereby give my consent that this minor receive counseling with the understanding that the minor is a client and is entitled to confidentiality. I therefore understand and agree that Tia Harms, counselor, shall not be obligated to inform me of information disclosed in counseling sessions unless it is deemed by the counselor to be a matter of safety to this minor client or others. Regarding requests for disclosure of information made by third parties, such as an attorney, judge, DHS case worker, legal guardian, or other parties, I understand that Tia Harms, counselor, will not be held responsible to provide confidential information to these parties. Only under special circumstance determined and agreed upon by both parents, legal guardians where appropriate, minor client, and Tia Harms, counselor, will a summary of treatment and progress be released. I, __________________________, minor to be receiving counseling, understand the above statement and agree to participate in counseling with Tia Harms, counselor.

_____________________________ Parent/Guardian Signature _____________________________ Client/Minor Signature ___________________ Date

____________________________ Counselor Signature