Minor child consent Form

Consent to Treatment of Minor Child(ren)

I hereby certify that I have the legal right to seek counseling treatment for minor(s) in my custody and give permission to Dr. Yiolanta Sofiali-Brunvert, LMHC to provide treatment to my minor child(ren). If I have unilateral decision-making capacity to obtain counseling services for my minor, I will provide the appropriate court documentation to Dr. Yiolanta Sofiali-Brunvert, LMHC prior to or at the initial session. Otherwise, I will have the other legal parent/guardian sign this consent for treatment prior to the initial session.



Your signature signifies that you have received a copy of the “Therapy Agreement, Policies and Consent” for your records