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This document should be completed by custodial parents and/or legal guardians of minors under the age of 15 years.  In cases where a formal/legal custody agreement is in effect (i.e., divorce, separation, adoption, non-parental guardian, etc.), please bring copies of all documents related to the custody agreement with you to the initial appointment.  In cases where two parties share joint legal custody (i.e., divorced/ separated parents), both parties must indicate their consent by signing both this form and the form entitled, “Information, Disclosure, and Consent” before treatment can begin. 
 

Child’s Name:___________________________________________DOB:____________

I/We___________________________________________________________________

am/are the legal custodial parent(s)/guardian(s) of______________________________

_______________________________________________________________________

and give my/our permission to Jennifer Ritchie-Goodline, Psy.D., to provide 
psychological services to my/our child.

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Custodial Parent/Guardian Signature                                                 Date

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Custodial Parent/Guardian Printed Name                                           Date

________________________________________________________________
Custodial Parent/Guardian Signature                                                 Date

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