Authorization for Treatment of Minor

I authorize:
Name of Minor
First Last
to participate in treatment provided by Dr. Tanya Mesirow. This authorization includes psychotherapy, assessment, evaluation, and testing. My signature below indicates that I agree to give consent for the treatment of my minor child. I also understand that parental participation may be requested.
Name
First Last
Date
MM slash DD slash YYYY
I am the:
- Parent
- Legal Guardian
Date
MM slash DD slash YYYY
Signature