Child's Name
First and last name of parent/guardian.
By typing your name below, you are indicating that you have read and understand this consent form.

First and last name of parent/guardian.
First and last name of mature minor / adolescent.
Email(Required)
I have had a chance to read and review the above-mentioned information with a psychologist and/or her clinic manager.(Required)
Consent(Required)
Videotape Consent(Required)
For internal use by the psychologist only.
Today's Date(Required)