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Unformatted text preview: [ FORM 10 —Use the top of this page for your letterhead.] Agreement for Psychotherapy with a Minor I, , the parent/legal guardian of the minor, , give my permis- sion for this minor to receive the following services/procedures/treatments/assessments: 1. 2. 3. These are for the purpose(s) of: 1. 2. 3. These services are to be provided by the therapist named above, or by another professional as the therapist sees fit. The fees for these services will be $ per session of service, or $ for the full services. This therapist’s office policies concerning missed appointments have been explained to me. I have been told about the risks and benefits of receiving these services and the risks and benefits of not receiving these services, for both this minor and his or her family. I agree that this professional may also interview, assess, or treat these other persons: 1. 3. 2. 4. Because of the laws of this state and the guidelines of the therapist’s profession, these rules concerning privacy will...
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This note was uploaded on 07/01/2010 for the course COUN 6682 A and taught by Professor All during the Spring '10 term at Walden University.

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