Parental Consent

We MUST have at least one parent signature, EXCEPT in cases where parents of a patient are divorced; both parents must consent at the start of treatment.  No further sessions will be held unless both parents consent to the patient receiving treatment, in accordance with Florida law.

My signature indicates that I agree to my minor child participating in mental health treatment with Hope Restored Services/Tonya Rowe.

    Date:*

    Patient Name:*

    Email:*

    Parent/Legal Guardian's Name (if applicable):

    Relationship to Patient:

    Patient or Guardian’s Signature:*

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    This e-mail was sent from a Parent Consent form on Hope Restored Services