Brighter Pathways, LLC

Minor Consent Form

Counseling is provided in order to assist children/teens many emotional and/or personal problems that may develop. All records regarding a student’s counseling are kept confidential except as required by law and are not included with records of others 

 Since your son or daughter is under age 18, we need your permission to provide any and all services with/for them. In some situations, including mental health emergencies, a signed permission form would not be required in order for us to render help.  However, it is strongly recommended that you sign the attached form and return it so that professional help in non-emergency situations may be provided to your child/teen.

As a general rule, I will keep the information you share with me in our sessions confidential, unless I have your written consent to disclose certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with me in a therapy session. In some situations, I am required by law or by the guidelines of my profession to disclose information whether or not I have your permission. 

Parent/Guardian: Check boxes and sign below indicating your agreement to respect your adolescent’s privacy: * 
Confidentiality cannot be maintained when: *
Do you understand the form? *
Do you agree/consent for your child to continue treatment; acknowledging understanding of his/her right to confidentiality and the therapist's obligations to break confidentiality? *
By signing below,  you agree to the terms as discussed above.
Signature *
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Relationship to patient? *
 
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100 Ashland Park Lane,   Suite E     Columbia, SC 29210
Phone: 803-708-7990    Fax: 803-636-2637   
Website:  www.brighterpathways-sc.com
Email:brighterpathwaysllc@gmail.com