Consent - Dr. Pure and Associates

Consenting Parent Only

Please be advised that your child has been referred for Psychological Services at this Practice. In order for us to proceed with the referral, we require your consent as a Joint Custodial Parent.

First and last name

By typing your name below, you are indicating that you have read and understand this consent form.

First Last

Email(Required)

Enter Email Confirm Email

First and last name of my child(Required)

First Last

Check one:(Required)

This section must be complete.

I will be paying for these services in full

I will be sharing the cost of these services with my child(ren)’s joint custodial parent

I will not be paying for any costs associated with these services.

If paying in part or full is checked above:

If not attending sessions, I will make arrangements for payment with the understanding that payment is due at the end of each session/service.

If I choose to provide my credit card information for payment, it will be kept confidential to this clinic and myself, and receipts will be provided directly to me in a manner arranged with this clinic. Providing my credit card information implies consent to process payment remotely for sessions/services for which I have been sent reminders in advance via email.

I wish to be notified of my child’s appointments(Required)

Yes

I wish to be included in my child’s therapy(Required)

Yes

Signature

Today's Date(Required)

Our Therapy Services

We have a diverse team with a wide range of specialties. To learn more visit the link below.

Therapy Services

Consenting Parent Only

Our Therapy Services

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