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

    Your information will be securely sent to and stored in Google Sheets for the purpose of processing your form submission.