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Form14 - son’s behavior and responses give me no reason...

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[ FORM 14 —Use the top of this page for your letterhead.] Consent to Treatment of a Child Name of child client: The therapist named below and I have discussed my child’s situation. I have been informed of the risks and benefits of several different treatment choices. The treatment chosen includes these actions and methods: 1. 2. 3. These actions and methods are for the purposes of: 1. 2. 3. I have had the chance to discuss all of these issues, have had my questions answered, and believe I understand the treatment that is planned. Therefore, I agree to play an active role in this treatment as needed, and I give this therapist (or another professional, as he or she sees fit) permission to begin this treatment, as shown by my signature below. Signature of parent/guardian Date I, the therapist, have discussed the issues above with the child’s parent or guardian. My observations of this per-
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Unformatted text preview: son’s behavior and responses give me no reason, in my professional judgment, to believe that this person is not fully competent to give informed and willing consent to the child’s treatment. Signature of therapist Date q Copy accepted by parent/guardian q Copy kept by therapist This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. FORM 14. Form for generic consent to treatment of a child. From The Paper Office . Copyright 2008 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details)....
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