Notice of Child Counseling – For Separated Parent

Notice of child counseling for separated/divorced parent

This form can be used to notify a “distant” parent that the other parent has brought their child for counseling, and to invite him/her to participate in the counseling process.

* * * * *

ACKNOWLEDGEMENT OF COUNSELING

          This release is an acknowledgement that Ms. Joyce Meagher, L.P.C., L.M.F.T., R.P.T.-S. is seeing my child __________________________________in counseling and that I am aware of the invitation by Ms. Meagher to participate in this counseling process.

        ____I accept the invitation to participate:

              _____in person

              _____by phone

              _____in writing

      ____I decline to participate

 

 Signature:______________________________________Date:_______________

  

NOTE: This is a sample form, designed for training purposes.
To the best of our knowledge, it is consistent with Virginia laws and regulations.
However, for use in your own setting, this form must be personalized
to reflect your state’s laws and your own actual policies.

 Provided to The Center for Ethical Practice by
Joyce Meagher, RN, LPC, LMFT, RPT-S, EMDR-C
She can be reached at LifeSpan Counseling
9675-B Main St., Fairfax A 22031
703-898-6952