Parental Release Form
My Minor Child
Is a patient of
While I am not the patient of Jodi Valentine Counseling Inc., I have participated or will be participating in the counseling process with my child. I hereby consent for
to release to
Person to release information to
information about myself and my minor child obtained by him/her during the course of my child’s counseling.
I also understand that it is recommended that both parents of the minor child attend every counseling session. In the event my minor child has a counseling session scheduled and I cannot attend for whatever reason, I hereby consent and agree that the appointment shall be kept and attended by my minor child and the other parent regardless of which parent has domiciliary custody at the time of the scheduled appointment. I also understand that information discussed in each session can and will be shared with either parent.
Parent/Guardian/Custodial Agency Authorization
By entering your name here, you are digitally signing this online form.